Nokea
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
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A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.40, HCO3- 24 mEq/L, PaCO2 38 mm Hg
- C. pH 7.45, HCO3- 28 mEq/L, PaCO2 40 mm Hg
- D. pH 7.50, HCO3- 30 mEq/L, PaCO2 45 mm Hg
Correct Answer: A
Rationale: The correct answer is A (pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg). In chronic kidney disease, the kidneys are unable to excrete acid effectively, leading to metabolic acidosis. The pH is low (acidotic) due to the accumulation of acids. The bicarbonate (HCO3-) is low (19 mEq/L) as the kidneys are unable to reabsorb and regenerate bicarbonate effectively. The PaCO2 is low (30 mm Hg) as the respiratory system compensates by increasing the respiratory rate to blow off carbon dioxide in an attempt to normalize the pH. Choices B, C, and D have pH values within normal range and do not reflect the expected acidosis in chronic kidney disease.
A nurse is preparing a client for radiation after a mastectomy. What adverse effect should be expected?
- A. Alopecia
- B. Diarrhea
- C. Fatigue
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation therapy often causes fatigue due to its impact on healthy cells surrounding the treatment area. This can result in decreased energy levels and overall tiredness. Alopecia (A) is more commonly associated with chemotherapy. Diarrhea (B) is a potential side effect of certain chemotherapy drugs or radiation to the abdominal area. Weight gain (D) is not a typical adverse effect of radiation therapy.
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Place the client in Trendelenburg position.
- C. Apply a warm compress to the wound.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
- A. Obtain a sputum culture
- B. Administer a chest X-ray
- C. Monitor for fever
- D. Provide oxygen therapy
Correct Answer: A
Rationale: The correct answer is A: Obtain a sputum culture. This is essential to identify the specific pathogen causing the pneumonia in the client with AIDS. By identifying the pathogen, appropriate antibiotic therapy can be initiated promptly. Administering a chest X-ray (B) may help in evaluating the extent of pneumonia but does not address the underlying cause. Monitoring for fever (C) is important but does not provide specific information needed for targeted treatment. Providing oxygen therapy (D) may be necessary but does not address the root cause of the pneumonia.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
- A. Reposition the client
- B. Check the chest tube for kinks
- C. Increase the suction pressure
- D. Administer pain medication
Correct Answer: A
Rationale: Repositioning the client can help alleviate chest burning caused by the chest tube.