Nokea
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. Hemoglobin of 12 g/dL
- B. Platelet count of 350,000/mm3
- C. CD4-T-cell count 180 cells/mm3
- D. White blood cell count of 10,000/mm3
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.
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While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Abnormally prominent U wave
- B. Tachycardia
- C. Flattened P wave
- D. Prolonged PR interval
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?
- A. Schilling test
- B. Complete blood count (CBC)
- C. Vitamin B12 level
- D. Bone marrow biopsy
Correct Answer: A
Rationale: The correct answer is A: Schilling test. Pernicious anemia is caused by vitamin B12 deficiency, often due to poor absorption. The Schilling test is specifically used to diagnose pernicious anemia by evaluating the body's ability to absorb vitamin B12. The test involves giving the patient a small amount of radioactive vitamin B12 to determine how well it is absorbed and utilized by the body. This test helps to differentiate pernicious anemia from other causes of B12 deficiency.
Choice B (Complete blood count) is a general test that may show abnormalities in red blood cells seen in anemia, but it does not specifically diagnose pernicious anemia. Choice C (Vitamin B12 level) alone may not differentiate between pernicious anemia and other causes of B12 deficiency. Choice D (Bone marrow biopsy) is not typically necessary for diagnosing pernicious anemia and is more invasive compared to the Schilling test.