A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse’s priority?
CD4-T-cell count 180 cells/mm³.
Positive Western blot test.
Platelets 150,000/mm³.
WBC 5,000/mm³.
The Correct Answer is A
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.
Choice B rationale
Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.
Choice C rationale
Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.
Choice D rationale
Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.
Correct Answer is D
Explanation
Choice A rationale
Diphenhydramine does not expand blood volume. It is an antihistamine used to prevent allergic reactions.
Choice B rationale
Diphenhydramine does not enhance clotting factors. It is used to manage allergic reactions.
Choice C rationale
While diphenhydramine can help manage fever and chills, its primary purpose before a blood transfusion is to prevent allergic reactions.
Choice D rationale
Administering diphenhydramine before a blood transfusion helps prevent urticaria and other allergic reactions by blocking histamine release. .
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