Exhibits

Reference Range

Red blood cells (RBC): 4.2 to 5.4 million/mm (4.2 to 5.4 x 10^6)

Hematocrit: 27 to 47%

Hemoglobin: 12.0 to 16.0 g/dL (120 to 160 g/L)

Please drag the condition from the choices above to fill in the blank in the sentence. Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developing

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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C"}

Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developing C. Postpartum hemorrhage.

The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

A. Monitor an IV infusion rate on an established schedule. B. Titrate oxygen to the prescribed parameters. C. Insert a urinary catheter for an uncomplicated patient. D. Procure platelet products from the blood bank.

Correct Answer is C

Explanation

Choice A rationale

Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.

Choice B rationale

Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).

Choice C rationale

Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.

Choice D rationale

Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

Correct Answer is B

Explanation

After receiving a change of shift report for patients on a medical-surgical unit, which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

The nurse is preparing discharge instructions for a patient with type 2 diabetes mellitus who will be starting exenatide.What information should be included in the discharge instructions?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea.Which source of contamination should the nurse consider when interviewing the client about exposure?

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?