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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Green leafy vegetables do not interact with cefdinir. They are generally a healthy choice and can be encouraged without any concerns related to the antibiotic therapy.
B. Fresh fruits are also safe to consume with cefdinir. There are no interactions between fruits and this antibiotic.
C. Yogurt and buttermilk contain probiotics, which are beneficial bacteria that can help maintain gut health. Antibiotics like cefdinir can disrupt the normal gut flora, leading to diarrhea or other gastrointestinal issues. Consuming yogurt or buttermilk with live cultures may help replenish beneficial bacteria in the gut and reduce the risk of antibiotic-associated diarrhea.
D. Avocados and cheese are also safe choices. There are no specific interactions between these foods and cefdinir.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.
Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.
Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.
The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.
Client Statement: B. The client says that she sometimes forgets why she is in the hospital.
Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.
Client Statement: D. The client is frightened that the hospital will burn down.
This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.
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