A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?

Positive Western blot test

CD4-T-cell count 505 cells/mm³ (nl. 500-1500 cells/mm³)

Platelets 115,000/mm³ (nl. 140,000-400,000/mm³)

White blood cell (WBC) count 800/mm³ (nl. 5000-10,000/mm³)

Answer and Explanation

The Correct Answer is D

A. A positive Western blot test confirms the diagnosis of HIV, but it is not concerning once the diagnosis has been established.
B. A CD4-T-cell count of 505 cells/mm³ is low but not critically low. While it does indicate immunosuppression, it is not the most concerning value presented.
C. A platelet count of 115,000/mm³ is lower than normal and may indicate a risk for bleeding, but it is not as concerning as a critically low white blood cell count.
D. A WBC count of 800/mm³ is severely low and indicates a high risk for infection, which is particularly concerning in a client with HIV, as it suggests significant immunosuppression and vulnerability to opportunistic infections.

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Correct Answer is B

Explanation

A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.

A. Placing the client on a ventilator to remove carbon dioxide (CO2) B. Advising the client to use their call light to reduce the risk of falls C. Providing the client a high protein diet D. Administering antibiotics and maintaining the mean arterial pressure (MAP) at least 65 mm Hg

Correct Answer is D

Explanation

A. Placing the client on a ventilator to remove CO2 is not directly related to preventing the development of MODS. While ventilation might be necessary for respiratory support, it does not address the systemic infection and inflammation that contribute to MODS.
B. Advising the client to use their call light to reduce the risk of falls is important for general safety but does not address the critical factors involved in preventing MODS in the context of SIRS.
C. Providing a high protein diet can support overall nutrition and healing but is not the primary intervention for preventing MODS. Managing the infection and maintaining hemodynamic stability are more critical.
D. Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.

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A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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