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

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Free Nursing Study Resources

Correct Answer is ["1.3"]

Explanation

Convert pounds to kilograms.

1 pound = 0.453592 kilograms
132 pounds * 0.453592 kg/pound = 59.87 kilograms

Step 2: Calculate the total dose in micrograms.

44 micrograms/kilogram * 59.87 kilograms = 2635.08 micrograms

Step 3: Convert micrograms to milligrams.

1 milligram = 1000 micrograms
2635.08 micrograms / 1000 micrograms/milligram = 2.63508 milligrams

Step 4: Calculate the volume to be administered.

Concentration of lorazepam = 2 milligrams/milliliter
Volume = Dose / Concentration
Volume = 2.63508 milligrams / 2 milligrams/milliliter = 1.31754 milliliters

Therefore, the nurse should administer approximately 1.3milliliters of the lorazepam solution.

A. The pressure dressing at right femoral area is moist and oozing blood. B. Pulse distal to the femoral artery is weaker on left foot than right foot. C. Right foot is cool to the touch and appears pale and blanched. D. Blood pressure trend is downward and pulse is rapid and irregular.

Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.3"]

Explanation

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

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