A nurse is caring for a client who has HIV and a CD4-T-cell count of 150/mm³. Which of the following conditions should the nurse monitor the client for?
Hepatitis
Tuberculosis
Gonorrhea
Chlamydia
The Correct Answer is B
A. Hepatitis is a concern for individuals with HIV, but it is not specifically indicated by a low CD4-T-cell count.
B. A CD4-T-cell count of 150/mm³ indicates severe immunosuppression, making the client highly susceptible to opportunistic infections like tuberculosis, which is common in individuals with HIV.
C. While gonorrhea is a risk for sexually active individuals, it is not specifically related to the low CD4-T-cell count.
D. Chlamydia is also a sexually transmitted infection, but similar to gonorrhea, it is not directly linked to the immunocompromised state indicated by the CD4-T-cell count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.
Correct Answer is ["D","E","F","G"]
Explanation
D. Measure lactate level: Elevated lactate levels are a strong indicator of sepsis and can help guide treatment.
E. Administer broad-spectrum antibiotics: Prompt administration of antibiotics is crucial to combat the infection.
F. Rapidly administer 30 mL/kg of normal saline: Aggressive fluid resuscitation is necessary to improve blood pressure and tissue perfusion.
G. Obtain blood cultures: Blood cultures can help identify the specific organism causing the infection and guide antibiotic therapy.
Other interventions that may be considered, but not necessarily within the first hour, include:
A. Obtain a urine specimen: This can help identify a urinary tract infection as a potential source of sepsis.
B. Insert a nasogastric tube: This may be necessary if the client is unable to tolerate oral intake or requires gastric decompression.
C. Type and cross-match for 2 units of packed RBCs: This may be necessary if the client develops significant anemia or requires blood transfusion.
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