Patient Data

Exhibits

Drag from Word Choices to complete the sentence.

According to the laboratory values, the client has
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; related to
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, or
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"A","dropdown-group-3":"E"}

Rationale for correct choices:

• Anemia: The client’s hemoglobin (9.3 g/dL) and hematocrit (30%) are both below normal, which indicates a reduced oxygen-carrying capacity of the blood, consistent with anemia.

• Blood loss: The abdominal hematoma, distension, and need for fluid bolus suggest internal bleeding after trauma, leading to a significant drop in hemoglobin and hematocrit.

• Hemodilution from intravenous fluids: The client received large volumes of IV fluids (bolus and maintenance infusion), which dilute circulating red blood cells, worsening the anemia picture.

Rationale for incorrect choices:

• Acidosis: No arterial blood gas (ABG) results are available yet, so there is no evidence to confirm a metabolic or respiratory acidosis at this stage.

• Hypovolemia: The client initially showed low blood pressure and tachycardia, but stabilization with fluids improved her vitals; the lab values specifically indicate anemia, not pure hypovolemia.

• Disseminated intravascular coagulation: PT and PTT are within normal limits, with no signs of uncontrolled clotting or bleeding, so DIC is not supported.

• Rh factor sensitization: The client is B+, but there is no mention of pregnancy or transfusion reactions that would trigger Rh-related hemolysis.

• Pregnancy: No history, findings, or labs indicate pregnancy, so this option is unrelated to the client’s current trauma and blood results.

• Hypoxia: Oxygen saturation remains 98–100% on mechanical ventilation, showing adequate oxygenation despite anemia.

• Blood administration: While the client may need transfusion, labs reflect anemia caused by blood loss and hemodilution, not from receiving blood products.

• Immune response: There are no clinical or laboratory findings of immune-mediated destruction of red cells or inflammation causing the anemia.

• Clotting cascade: Normal PT and PTT show the coagulation pathway is intact, ruling out clotting disorders as the cause of low hemoglobin and hematocrit.

• Hypoventilation: The client is mechanically ventilated with normal oxygenation, and there is no evidence of hypoventilation contributing to her anemia.

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Correct Answer is C

Explanation

A. Prone: Prone positioning limits assessment of spinal curvature, extremity alignment, and body symmetry because the client is lying on the abdomen, which can obscure certain postural deviations.

B. Sims: Sims position is primarily used for rectal or vaginal procedures and does not provide a full view of overall body alignment, making it less ideal for assessment purposes.

C. Supine: Supine position allows the client to lie flat on the back with the body fully supported. This position provides the best view of the head, neck, spine, shoulders, hips, and extremities for a comprehensive assessment of body alignment.

D. Fowlers: Fowlers position elevates the head and torso, which may alter natural spinal alignment and obscure an accurate assessment of posture and symmetry compared with a flat, supine position.

A. Use nasal or cough tissues followed by handwashing at all times. B. Ensure supplemental oxygen and respiratory medications are available at all times. C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines. D. Avoid large crowed areas during the colder months of the year.

Correct Answer is C

Explanation

A. Use nasal or cough tissues followed by handwashing at all times: Hand hygiene and respiratory etiquette are important to reduce infection risk, but they are general preventive measures and not as critical as vaccination for high-risk clients with chronic respiratory diseases.

B. Ensure supplemental oxygen and respiratory medications are available at all times: Having medications and oxygen ready is important for managing acute symptoms, but it does not prevent illness or complications; it is part of ongoing disease management not prevention.

C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines: Vaccination is the most important preventive measure for clients with asthma, chronic bronchitis, or emphysema. These clients are at higher risk for respiratory infections, which can cause severe exacerbations, hospitalization, and complications.

D. Avoid large crowded areas during the colder months of the year: Limiting exposure can reduce infection risk but is a situational preventive measure. Vaccination provides broader and more effective protection against common respiratory pathogens.

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Patient Data Exhibits Drag from Word Choices to complete the sentence. According to the laboratory values, the client has dropdown ; related to dropdown , or dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the body alignment of an immobilized client. Which is the best client position for the nurse to obtain an accurate assessment?

Correct Answer is C

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Correct Answer is C

Explanation

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.

The nurse is planning care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

Patient Data

Exhibits

Drag from Word Choices to complete the sentence.

According to the laboratory values, the client has
dropdown
; related to
dropdown
, or
dropdown
.