Author Question: The client with human immunodeficiency virus (HIV) infection has been started on therapy with ... (Read 84 times)

tiffannnnyyyyyy · **on:** Jul 22, 2018

The client with human immunodeficiency virus (HIV) infection has been started on therapy with zidovudine (AZT, Retrovir).

The nurse reviews the physician's prescriptions, expecting to note that which of the following laboratory tests have been prescribed? 1. Blood culture
2. Blood glucose level
3. Blood urea nitrogen level (BUN)
4. Complete blood cell count (CBC)

Question 2

The male client complains of pain as the nurse is inflating the balloon following insertion of a Foley catheter. The nurse takes which of the following actions immediately?

1. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
2. Remove the catheter, and reinsert a new one that is one size smaller.
3. Finish inflating the balloon; the discomfort is normal and temporary.
4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

Jsherida · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4

Rationale: An adverse effect of this medication therapy is agranulocytopenia and anemia. The nurse carefully monitors the CBC for these changes. With early HIV infection or in the client who is asymptomatic, CBC levels are monitored monthly for 3 months, and then every 3 months thereafter. In clients with advanced disease, these levels are monitored every 2 weeks for the first 2 months, and then once a month if the medication is tolerated well. Blood culture, blood glucose level, and blood urea nitrogen level (BUN) are unrelated to this medication.

Answer to Question 2

4

Rationale: If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid should be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter should not be withdrawn slightly (aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon) because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon should not continue to be inflated because the pain is not normal and will not go away.