Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
A. WBC 5,000/mm3
B. Platelets 150,000/mm3
C. Positive Western blot test
D. CD4-T-cell count 180 cells/mm3
CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.
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Full Explanation
CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.
Similar Questions
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
A. Instruct the client to use pursed-lip breathing.
This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.
B. Provide the client with a low-protein diet.
C. Have the client use the early-morning hours for exercise and activity.
D. Restrict the client's fluid intake to less than 2 L/day.
Full Explanation
This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
A. Oxygen saturation level 96%
B. Respiratory alkalosis
C. Petechiae on chest
D. Increased anteroposterior diameter of the chest
This is because emphysema causes destruction of alveolar walls and loss of elastic recoil, which leads to air trapping and hyperinflation of the lungs. This results in a barrel-shaped chest and increased chest circumference.
Full Explanation
This is because emphysema causes destruction of alveolar walls and loss of elastic recoil, which leads to air trapping and hyperinflation of the lungs. This results in a barrel-shaped chest and increased chest circumference.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
A. Iritis
B. Wrinkles in the skin
C. Facial rash
This is because SLE is an autoimmune disorder that causes inflammation and damage to various tissues and organs, including the skin. A facial rash, also known as a malar rash or butterfly rash, is one of the characteristic signs of SLE and affects about half of people with the condition.
D. Constipation
Full Explanation
This is because SLE is an autoimmune disorder that causes inflammation and damage to various tissues and organs, including the skin. A facial rash, also known as a malar rash or butterfly rash, is one of the characteristic signs of SLE and affects about half of people with the condition.