The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; 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); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm (14 x 10^9/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 [5000 to 10,000/mm² (5 to 10 x 10^9/L)].

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

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

Increase Client A's oxygen to 4 liters a minute per cannula.

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

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.

Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.

Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.

Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale:

Assisting in discharging stable clients to home is not the most appropriate assignment when a mass casualty event has occurred. During such events, resources are needed for critically injured patients, and stable clients can typically be discharged by non-emergency staff.

Choice B rationale:

Determining the acuity and number of casualties arriving at the facility is the most appropriate assignment during a mass casualty event. This information is critical for allocating resources and providing the necessary level of care to those affected.

Choice C rationale:

Delegating tasks to emergency healthcare specialists may be necessary, but it is not the initial assignment for the nurse working on a medical-surgical unit. Assessing the situation and determining the acuity of incoming casualties take precedence.

Choice D rationale:

Providing informational updates to members of the media is not the role of a nurse during a mass casualty event. This task should be handled by hospital public relations or designated spokespersons to ensure accurate and controlled information dissemination.

A. Assign the newly hired UAP to clients who require the least complex level of care. B. Ask the most experienced UAP on the team to partner with the newly hired UAP. C. Review the UAP's skills checklist and experience with the person who hired the UAP. D. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

Correct Answer is D

Explanation

Choice A rationale:

Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.

Choice B rationale:

Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.

Choice C rationale:

Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

Correct Answer is B

Explanation

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

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?

A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

What are some important nursing considerations for this medication? *.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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?

A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?