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A nurse is caring for a client in the clinic.

Exhibits

The nurse anticipates which of the following orders from the provider based on the suspected diagnosis? (Select all that apply)

A.

IV antibiotics

B.

Urinalysis

C.

Chest x-ray

D.

Chest tube placement

E.

Admit to inpatient

F.

Airborne precautions

G.

Draw an STI lab panel

H.

Complete blood count

Answer and Explanation

Correct Answer : A,C,E,H

The nurse anticipates the following orders from the provider based on the suspected diagnosis:

  • A. IV antibiotics: To treat the suspected infection.
  • C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
  • E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
  • H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.

Rationale:

  • B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
  • D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
  • F. Airborne precautions: This is not necessary for the client's current condition.
  • G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.


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Related Questions

Correct Answer is A

Explanation

A. Respiratory acidosis is characterized by a low pH (7.32) and an elevated PaCO2 (48 mm Hg), indicating that the body is unable to eliminate CO2 effectively, leading to acid retention. The HCO3 level is within normal limits, suggesting that there is not a metabolic compensation occurring yet.
B. Metabolic alkalosis would present with a high pH and elevated bicarbonate levels, which is not the case here.
C. Respiratory alkalosis typically shows a high pH and low PaCO2, indicating hyperventilation, which does not align with the current findings.
D. Metabolic acidosis would show a low pH with a low HCO3, which is not supported by the HCO3 level of 23 mEq/L in this case.

Correct Answer is A

Explanation

A. The CD4-T-cell count of 180 cells/mm3 is a critical measure of immune function in an HIV-positive client, indicating progression of the disease and risk for opportunistic infections. Values below 200 cells/mm3 signify the client has progressed to AIDS.
B. A positive Western blot test confirms the presence of HIV but does not indicate the immediate health risk or necessary interventions.
C. A platelet count of 150,000/mm3 is within the normal range, thus not indicative of any urgent concerns.
D. A WBC count of 5,000/mm3 is also within normal limits and does not highlight an immediate issue that needs addressing compared to the CD4 count.

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