Arterial Blood Gas Laboratory Test

Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.

Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.

Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.

Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.

Choice A rationale

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Choice B rationale

Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.

Choice C rationale

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Choice D rationale

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.