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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.
Choice B rationale:
Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.
Choice C rationale:
Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.
Choice D rationale:
Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.
Correct Answer is B
Explanation
Choice A rationale:
4012 mg/day is not the correct answer. To calculate the maximum safe dosage of valproic acid, you need to convert the client's weight from pounds to kilograms. The client's weight in kilograms can be calculated by dividing the weight in pounds by 2.2. Therefore, 176 pounds divided by 2.2 equals 80 kilograms. The maximum safe dosage is 60 mg/kg/day, so 60 mg multiplied by 80 kg equals 4800 mg/day.
Choice B rationale:
Step 1: Convert the client’s weight from pounds to kilograms. We know that 1 kg is approximately equal to 2.2 pounds. So, we have:
176 pounds ÷ 2.2 = 80 kg (approximately)
Step 2: Calculate the maximum safe dosage for the client. We know that the maximum safe dosage of valproic acid is 60 mg/kg/day. So, we have:
60 mg/kg/day × 80 kg = 4800 mg/day
So, the maximum safe dosage for a client who weighs 176 pounds is4800 mg/day.
Choice C rationale:
3520 mg/day is not the correct answer. It does not accurately calculate the maximum safe dosage based on the client's weight.
Choice D rationale:
6171 mg/day is not the correct answer. It is significantly higher than the correct calculation and would exceed the maximum safe dosage for the client's weight.
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