A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?
Positive Western blot test
CD4-T-cell count 180 cells/mm³ (Range: 500 to 1500 cells/mm³)
Platelets 150,000/mm³ (Range: 150,000-400,000 cells/mm³)
WBC 5,000/mm³ (Range: 5,000-10,000 cells/mm³)
The Correct Answer is B
A. A positive Western blot test indicates an HIV diagnosis, which is expected in a client with HIV and does not require urgent intervention.
B. A CD4-T-cell count of 180 cells/mm³ is significantly low (normal range: 500 to 1500 cells/mm³) and indicates severe immunosuppression, putting the client at increased risk for opportunistic infections, warranting immediate attention from the provider.
C. A platelet count of 150,000/mm³ is at the lower end of the normal range and does not typically require immediate intervention unless there are clinical symptoms associated.
D. A WBC count of 5,000/mm³ is within the normal range and does not indicate a need for urgent intervention.
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Correct Answer is ["B","C","D","E","F"]
Explanation
A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.
B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.
C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.
D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.
E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.
F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.
G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.
Correct Answer is D
Explanation
A. Blood transfusions are not a primary treatment for pernicious anemia; they may be used in severe cases but do not address the underlying cause of the condition, which is vitamin B12 deficiency.
B. Daily hydroxyurea is primarily used to treat certain types of cancer and sickle cell disease, not pernicious anemia.
C. Iron supplements are not effective in treating pernicious anemia, as the condition is due to a deficiency of vitamin B12, not iron.
D. Vitamin B injections are the correct intervention for pernicious anemia because the condition results from an inability to absorb vitamin B12 due to a lack of intrinsic factor, making injections necessary to restore vitamin levels.