A nurse is reviewing a client’s complete blood count (CBC) and notes an RBC count of 3.5 million/mm³ and a mean corpuscular volume (MCV) of 102 mm³. Based on these values, the most appropriate action for the nurse would be to:

Administer vitamin B12 to increase RBC size.

Administer vitamin B12 to restore normal RBC maturation.

Administer medication to decrease RBC size.

Administer iron to increase the formation of hemoglobin molecules.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering vitamin B12 to increase RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to increase RBC size.
Choice B rationale
Administering vitamin B12 to restore normal RBC maturation is the appropriate action. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency.
Administering vitamin B12 will help restore normal RBC maturation and correct the anemia.
Choice C rationale
Administering medication to decrease RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to decrease RBC size.
Choice D rationale
Administering iron to increase the formation of hemoglobin molecules is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. Iron supplementation is typically used for microcytic anemia, not macrocytic anemia.

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Correct Answer is A

Explanation

Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.

A. This intracellular substance can leak into the blood with cardiac cellular injury or death. B. Elevated serum levels of troponin occur because of sustained glycogenolysis. C. This substance is elevated when a patient has acute tubular necrosis. D. Serum elevation of this acute phase reactant occurs because of tissue injury.

Correct Answer is A

Explanation

Choice A rationale
Elevated serum levels of troponin indicate cardiac cellular injury or death. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, such as during a myocardial infarction.
Choice B rationale
Sustained glycogenolysis does not cause elevated troponin levels. Glycogenolysis is the breakdown of glycogen to glucose, primarily occurring in the liver and muscles, not related to troponin release.
Choice C rationale
Acute tubular necrosis does not elevate troponin levels. This condition affects the renal tubules and is typically indicated by elevated creatinine and BUN levels.
Choice D rationale
Troponin is not an acute phase reactant. Acute phase reactants are proteins whose levels change in response to inflammation, such as C-reactive protein (CRP), not troponin.

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A nurse is reviewing a client’s complete blood count (CBC) and notes an RBC count of 3.5 million/mm³ and a mean corpuscular volume (MCV) of 102 mm³. Based on these values, the most appropriate action for the nurse would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with suspected meningitis. Which of the following signs would be most indicative of meningitis?

Correct Answer is A

Explanation

What is the significance of elevated serum levels of troponin?

Correct Answer is A

Explanation

A client with a long history of cirrhosis has anemia, leukopenia, and thrombocytopenia. In the context of cirrhosis, these three conditions are most likely caused by:

A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

A nurse has identified a fluid volume deficit in the patient who has suffered prolonged vomiting and diarrhea. Which assessment data is most important in identifying that the patient may be developing prerenal acute kidney injury (AKI)?

A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

A client with diabetes mellitus presents with a foot ulcer that is not healing. Which of the following factors could be contributing to the delayed healing?