a cd4 lymphocyte count is performed on a client who is infected with hiv the results of the test indicate a cd4 count of 450 cellsl the nurse interpre
Logo

Nursing Elites

HESI RN

HESI RN Medical Surgical Practice Exam

1. A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:

Correct answer: B

Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.

2. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

Correct answer: D

Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.

3. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8°F (37.6°C). What is the most appropriate action by the nurse?

Correct answer: C

Rationale: After hemodialysis, it is crucial to monitor the client's temperature because the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature might reflect the temperature of the dialysate. There is no need to administer fluids to increase blood pressure as the vital signs are within normal limits. Checking the white blood cell count or connecting the client to an ECG monitor is not necessary based on the information provided.

4. In a patient with diabetes mellitus, which of the following is a sign of hypoglycemia?

Correct answer: C

Rationale: Sweating is a common sign of hypoglycemia in diabetic patients. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, which can cause sweating as a response to the perceived danger. Polydipsia (excessive thirst) and polyuria (excessive urination) are actually more commonly associated with hyperglycemia, not hypoglycemia. Dry skin is not typically a sign of hypoglycemia.

5. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Correct answer: D

Rationale: The correct answer is D. Drinking several bottles of carbonated water daily may contribute to renal calculi formation due to the high mineral content. Carbonated drinks can increase the risk of kidney stones due to their high levels of phosphoric acid and caffeine, which can lead to the formation of crystals in the urine. Choices A, B, and C are less likely to directly contribute to an increased risk of renal calculi compared to the excessive consumption of carbonated water.

Similar Questions

A client with chronic renal failure is receiving erythropoietin therapy. The nurse should assess the client for which of the following side effects?
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
The nurse is caring for a patient who is receiving oral potassium chloride supplements. The nurse notes that the patient has a heart rate of 120 beats per minute and has had a urine output of 200 mL in the past 12 hours. The patient reports abdominal cramping. Which action will the nurse take?
Which of the following conditions is most commonly associated with a high risk of stroke?
Which of the following is a key symptom of appendicitis?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses