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A nurse in a health clinic is caring for a client.

Select 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

due to 

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

​​​​​​​Condition Choices

  • Dysrhythmias: Dysrhythmias are often linked to electrolyte imbalances, particularly potassium abnormalities, rather than WBC count changes. The client’s potassium level remains within normal limits, making dysrhythmias unlikely.
  • Infection: A decreasing WBC count below the normal range weakens the immune response, increasing susceptibility to infections. The client’s WBC count has declined from 4,500/mm³ to 4,100/mm³, placing them at higher risk for opportunistic infections, a major concern in HIV.
  • Renal failure: Renal failure is typically assessed through elevated BUN and creatinine levels, along with signs of fluid imbalance. The client’s BUN is slightly elevated but not significantly high, and there are no other indicators of renal failure.
  • Bleeding: Bleeding risk is associated with low platelet levels, which impair clotting ability. The client’s platelet count remains within normal limits, reducing the likelihood of bleeding complications.
  • Seizures: Seizures can result from severe electrolyte imbalances, neurological conditions, or uncontrolled infections. The client does not exhibit signs of neurological dysfunction, and electrolyte levels are stable, making seizures unlikely.

Finding Choices

  • WBC count: A declining WBC count below the normal range weakens the immune response, making the client more susceptible to infections. This is particularly concerning for individuals with HIV, as they are already at an increased risk for opportunistic infections.
  • Potassium level: Potassium levels are crucial for cardiac function and neuromuscular stability. The client’s potassium level remains within normal limits, making it an unlikely contributor to any immediate risk.
  • Platelets: Platelets play a key role in clot formation. The client’s platelet count is within the normal range, so they are not currently at increased risk for bleeding.
  • Sodium level: Sodium is essential for fluid balance and neurological function. The client’s sodium level remains within the normal range, meaning it is not contributing to any immediate concerns.
  • BUN level: Elevated BUN levels can indicate impaired kidney function, dehydration, or increased protein metabolism. The client’s BUN level has increased slightly but is still within the normal range, making renal failure unlikely at this time.


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Related Questions

Correct Answer is C

Explanation

A. Sore throat: A sore throat is a common and expected finding after extubation due to irritation and mild inflammation of the airway. While discomfort may persist, it does not typically require immediate intervention.

B. SaO2 92%: An oxygen saturation of 92% is slightly lower than normal but is generally acceptable in most patients following extubation. Close monitoring is necessary, but immediate intervention is not required unless the saturation continues to decline.

C. Stridor: Stridor is a high-pitched, harsh sound caused by upper airway obstruction, often due to post-extubation laryngeal edema. This is a medical emergency requiring immediate intervention, such as administration of nebulized epinephrine, corticosteroids, or reintubation if severe airway compromise occurs.

D. Rhonchi: Rhonchi are low-pitched, coarse lung sounds caused by mucus or secretions in the airways. This finding may indicate the need for suctioning or respiratory therapy but does not require urgent intervention compared to stridor.

Correct Answer is D

Explanation

A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.

B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.

C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.

D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.

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