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.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.

Choice B rationale:

This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.

Choice C rationale:

This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.

Choice D rationale:

This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.

A. Encourage the client to exercise every day to eliminate bedtime wakefulness. B. Advise the client that lifestyle changes often take several weeks to be effective. C. Ask the client for a description of the exercise schedule that is being followed. D. Determine the amount of weight the client has lost since increasing activity.

Correct Answer is B

Explanation

The correct answer is Choice B: Advise the client that lifestyle changes often take several weeks to be effective.

Choice B rationale: Exercise is known to improve sleep quality and reduce the time it takes to fall asleep; however, these benefits may not be immediate. Lifestyle modifications, such as incorporating regular physical activity, typically require several weeks before noticeable improvements in sleep patterns and overall health are observed. By informing the client about this expected timeframe, the nurse promotes realistic expectations and encourages adherence to the exercise program.

Choice A rationale: Encouraging daily exercise to eliminate bedtime wakefulness may be counterproductive, as overexertion can lead to increased arousal and impaired sleep quality. Additionally, daily exercise might be too rigorous or impractical for some individuals, potentially leading to burnout or injury. It is essential to tailor exercise recommendations to the client's fitness level, preferences, and goals.

Choice C rationale: While obtaining information about the client's exercise schedule is helpful in assessing their adherence and progress, it does not directly address the issue of sleep onset difficulties. The nurse should focus on providing education and guidance on the expected timeline for observing sleep improvements with exercise.

Choice D rationale: Weight loss is a potential outcome of increased physical activity but is not directly correlated with improvements in sleep onset latency. Focusing solely on weight loss may overlook other essential aspects of sleep hygiene and healthy lifestyle changes. The nurse should emphasize the broader benefits of exercise and provide a comprehensive approach to addressing the client's concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement?

Correct Answer is B

Explanation

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 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?

A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client?

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

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

A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.