A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Notify the primary health care provider and request antibiotics.

Inform the client that this signifies inflammation.

Document findings and continue monitoring.

Place the client in protective isolation.

Answer and Explanation

The Correct Answer is A

Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.

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Correct Answer is B

Explanation

Choice A rationale:
Explaining legal requirements to inform sex partners at this initial stage is not the most appropriate or supportive intervention.
The client is in a state of emotional distress and may not be receptive to information about legal obligations. It's crucial to first address the client's emotional needs and provide support before discussing legal matters.
Prematurely focusing on legalities could further overwhelm the client and potentially hinder the development of a trusting relationship with the nurse.
Choice C rationale:
Offering to inform the family for the client, while well-intentioned, may not respect the client's autonomy and right to privacy. The decision to disclose HIV status to family members is a personal one that should be made by the client, not the nurse.
It's important to empower the client to make their own choices about disclosure and provide support throughout the process.
Choice D rationale:
Determining if a clergy member would help could be a valuable resource for some clients, but it should not be the first or only intervention.
It's essential to first assess the client's individual needs and preferences regarding spiritual support.
Not all clients may find comfort in religious or spiritual guidance, and some may prefer to seek support from other sources.
Choice B rationale:
Assessing the client for support systems is the most appropriate initial intervention because it focuses on the client's immediate needs for emotional support and connection.
By identifying existing support systems (such as family, friends, or community organizations), the nurse can help the client access resources that can provide comfort, understanding, and assistance in coping with the diagnosis.
This approach recognizes the client's emotional state and prioritizes their psychosocial well-being, which is essential in the initial stages of coping with an HIV diagnosis.

A. Institute hourly neurologic checks. B. Initiate cardiac monitoring. C. Initiate seizure precautions. D. Administer oxygen via face mask.

Correct Answer is B

Explanation

Choice A rationale:
Hourly neurologic checks are not the priority intervention for a client with hypokalemia. While hypokalemia can cause neuromuscular changes, such as muscle weakness and cramps, these are not typically the most immediate or life-threatening concerns.
Cardiac monitoring is crucial to detect and manage potentially fatal arrhythmias promptly.

Neurologic checks can be implemented as part of the overall assessment and monitoring plan, but they should not supersede cardiac monitoring in this situation.
Choice C rationale:
Seizure precautions are not routinely initiated for clients with hypokalemia unless there is a specific seizure history or other neurological concerns.
Hypokalemia can cause neuromuscular irritability, but it does not directly trigger seizures in most cases. The priority remains cardiac monitoring due to the significant risk of arrhythmias.
Choice D rationale:
Administering oxygen via face mask might be considered if the client exhibits respiratory distress or hypoxemia. However, it's not the immediate priority intervention for hypokalemia without accompanying respiratory compromise.
Hypokalemia primarily affects cardiac conduction, necessitating prompt cardiac monitoring.
Oxygen therapy can be administered if clinically indicated, but it does not address the underlying electrolyte imbalance.
Rationale for the correct answer, B:
Initiating cardiac monitoring is the most crucial nursing action for a client with a serum potassium level of 2.8 mEq/L. Here's a detailed explanation:
Hypokalemia's significant cardiac effects:
Potassium is essential for normal cardiac conduction and muscle contraction. Hypokalemia disrupts the electrical activity of the heart, potentially leading to:
Arrhythmias (irregular heartbeats), including potentially fatal ones like ventricular tachycardia or fibrillation. Electrocardiogram (ECG) changes, such as ST segment depression, T wave flattening or inversion, and prominent U waves. Cardiac monitoring's role:
Continuously tracks the heart's electrical activity. Enables early detection of arrhythmias.
Facilitates prompt intervention to prevent life-threatening complications. Specific benefits of cardiac monitoring in hypokalemia:

Allows for early identification and treatment of arrhythmias, potentially preventing cardiac arrest. Guides electrolyte replacement therapy, ensuring appropriate potassium administration.
Assesses the effectiveness of interventions, ensuring the patient's stability.

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A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What is the best intervention by the nurse?

Correct Answer is B

Explanation

The nurse is reviewing a client’s laboratory results and notes the serum potassium level is 2.8 mEq/L. Which nursing action should be initiated immediately?

Correct Answer is B

Explanation

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