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
.

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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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

A. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is indicated for immunocompromised clients, not for MRSA wound infections. It does not reduce transmission or address wound healing.

B. Use standard precautions and wear a mask: Standard precautions are necessary, but a mask is not required for MRSA unless there is risk of aerosolization (e.g., respiratory infection). The key precaution is contact isolation, not routine mask use.

C. Monitor the client’s white blood cell count (WBC): Tracking WBC trends helps identify worsening infection or systemic involvement such as sepsis. This is an important part of managing MRSA.

D. Institute contact precautions for staff and visitors: MRSA is transmitted by direct contact with infected drainage or contaminated surfaces, so gown and glove use with contact precautions are essential.

E. Send wound drainage for culture and sensitivity: Culturing identifies the causative organism and determines antibiotic sensitivity, which guides effective treatment planning.

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours. B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle. C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

Correct Answer is D

Explanation

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours: Intermittent collection is not used for a 24-hour urine test; continuous collection of all urine after the start time is required to accurately measure creatinine clearance.

B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This procedure is for a clean-catch or midstream urine specimen, not a 24-hour collection, and does not provide the total volume needed for creatinine clearance.

C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Catheterization is unnecessary for routine 24-hour urine collection and increases infection risk. The client can collect urine in a provided container.

D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void establishes the start of the collection period, and collecting all urine for the next 24 hours ensures accurate measurement of creatinine clearance.

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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

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.

Correct Answer is ["C","D","E"]

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is D

Explanation

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

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
.