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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.

Choice B rationale

Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.

Choice C rationale

Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.

Choice D rationale

Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.

A. Expect reduced vision for 48 hours after the procedure. B. Restrict lifting objects greater than 10 pounds. C. Take aspirin for discomfort. D. Apply warm compresses for discomfort.

Correct Answer is B

Explanation

Choice A rationale

Vision may be temporarily blurred after intraocular lens surgery, but significant vision reduction for 48 hours is not typical and should be reported to a healthcare provider.

Choice B rationale

Restricting lifting objects greater than 10 pounds is crucial to prevent increased intraocular pressure and potential complications after surgery.

Choice C rationale

Aspirin should be avoided as it can increase the risk of bleeding. Alternative pain relief methods should be used.

Choice D rationale

Warm compresses are not recommended as they can increase inflammation and discomfort. Cold compresses may be more appropriate.

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A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse’s priority?

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A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse’s priority?