A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
Call a chaplain
Maintain the client’s blood pressure
Provide the spouse a chair
Ask the client’s spouse to explain what happened
The Correct Answer is B
Choice A reason: Calling a chaplain is not the priority nursing action for a client who is in critical condition and hypotensive. The chaplain may not be available or may not be able to provide adequate support to the spouse. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Choice B reason: Maintaining the client’s blood pressure is the priority nursing action for a client who is in critical condition and hypotensive. The nurse should monitor the client’s vital signs, administer fluids and medications, and provide oxygen as ordered. This choice addresses the client’s urgent medical needs and may prevent further complications.
Choice C reason: Providing the spouse a chair is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not want to sit down or may not be able to stay calm. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Choice D reason: Asking the client’s spouse to explain what happened is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not be able to recall or communicate the details of the event. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.
Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.
Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.
Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.
Correct Answer is C
Explanation
Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.
Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.
Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.
Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.
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