A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:
While the white blood cell (WBC) count is important in assessing the immune system's ability to fight infection, a WBC of 5,000/mm³ is within the normal range (4,500 to 11,000 WBCs/mm³). Therefore, it is not the most critical value for a nurse to prioritize in the care of an HIV patient.

Choice B reason:
A platelet count of 150,000/mm³ is also within the normal range (150,000 to 450,000 platelets/mm³). Although thrombocytopenia can occur in HIV, this value does not indicate an immediate concern for the nurse to prioritize.

Choice C reason:
A positive Western blot test confirms the presence of HIV antibodies, which is indicative of HIV infection. However, this is a diagnostic result rather than a laboratory value that reflects the current status of the patient's immune function or disease progression.

Choice D reason:
The CD4-T-cell count is a critical laboratory value for assessing the immune function of a patient with HIV. A count of 180 cells/mm³ is below the normal range of 500 to 1,200 cells/mm³ and indicates a significantly weakened immune system, placing the patient at risk for opportunistic infections. This value is a priority as it guides treatment decisions and the need for prophylaxis against opportunistic infections.

Choice A reason:
While monitoring urinary output is important after surgery to ensure kidney function and that the urinary tract has not been compromised during surgery, it is not the immediate priority. The nurse should ensure that the client is not experiencing postoperative complications such as urinary retention, but this comes after the assessment of vital signs.

Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following an abdominal hysterectomy. Maintaining adequate oxygenation is critical after anesthesia, as respiratory function can be compromised. The nurse must ensure the client's airway is clear and that they are receiving sufficient oxygen to prevent hypoxia and other respiratory complications.

Choice C reason:
Inspecting the abdominal dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.

Choice D reason:
Pain management is a significant part of postoperative care, and the nurse will need to assess the client's pain level to manage it effectively. However, the immediate priority is to ensure the client's vital signs are stable, which includes oxygen saturation, before addressing pain.