A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?.
Cellular hypoxia.
Prolonged bleeding.
Fluid retention.
Impaired immunity.
The Correct Answer is A
Choice A rationale:
Hemoglobin of 10 g/dL and hematocrit of 30% are lower than the normal ranges (Hemoglobin: 13.5-17.5 g/dL for men, 12.0-15.5 g/dL for women; Hematocrit: 38.8-50.0% for men, 34.9-44.5% for women). This can lead to cellular hypoxia as there are fewer red blood cells to carry oxygen.
Choice B rationale:
These lab values do not directly indicate a risk for prolonged bleeding.
Choice C rationale:
These lab values do not directly indicate a risk for fluid retention.
Choice D rationale:
While severe anemia can affect the immune response, these values do not directly indicate impaired immunity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Impulsive behavior is more commonly associated with right hemispheric CVAs.
Choice B rationale:
This statement is incorrect. A left hemispheric CVA typically results in right-side motor function impairment.
Choice C rationale:
This statement is incorrect. Loss of depth perception is more commonly associated with right hemispheric CVAs.
Choice D rationale:
This statement is correct. Left hemispheric CVAs often result in language and speech impairments, so establishing effective communication would be a key goal in rehabilitation.
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