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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Correct Answer is ["18"]

Explanation

(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.

For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.

Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.

A. Fluid resuscitation due to capillary leaking. B. Replacement of insensible water loss. C. Extension of plasma until blood is available. D. Restoration of electrolyte balance.

Correct Answer is A

Explanation

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["18"]

Explanation

Correct Answer is A

Explanation

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?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.