The nurse is caring for four clients:

Client A, who has emphysema and whose oxygen saturation is 94% on room air;

Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L);

Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L);

Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 109/L).

Which intervention should the nurse implement?Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

White Blood Cell [5,000 to 10,000/mm3 (5 to 10 x 109/L)]

Move Client D into an isolation room 24 hours before surgery.

Verify that Client B has two units of packed cells available.

Ask the dietitian to add a banana to Client C's breakfast tray.

Increase Client A's oxygen to 4 L/minute via nasal cannula.

Answer and Explanation

The Correct Answer is B

Rationale

A. Client A's oxygen saturation is acceptable for someone with emphysema.

B. This is because Client B's postoperative hemoglobin level is 8.2 mg/dL, which is significantly lower than the normal reference range of 14 to 18 g/dL. This indicates that Client B is anemic and may require a blood transfusion to increase the hemoglobin level.

C. Client C's potassium level is within the normal range

D. Client D's WBC count is elevated, moving them into isolation is not indicated solely based on an elevated WBC count.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.

B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.

C. Redressing the site without assessment does not address the client's complaint of pain.

D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

A. Serum albumin. B. Neutrophil count. C. Serum blood glucose (BG) level. D. Hematocrit.

Correct Answer is B

Explanation

Rationale

A. Although low serum albumin levels can impact wound healing, they are not directly related to the presence of purulent drainage.

B. Neutrophils are a type of white blood cell involved in the body's immune response, particularly against bacterial infections. An elevated neutrophil count (neutrophilia) can indicate an acute infection or inflammation, including in wounds.

C. High blood glucose levels can predispose the client to infections, including wound infections. While it's important to monitor blood glucose levels, it is less directly relevant to the immediate concern of purulent drainage from the burn wound.

D. Hematocrit measures the proportion of red blood cells in the blood and is used to assess hydration status and oxygen-carrying capacity. In burn patients, changes in hematocrit can indicate fluid shifts and potential dehydration. Fluid shifts and dehydration can influence wound healing and overall patient condition but are not directly related to the presence of purulent drainage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is B

Explanation

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

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?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?