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 B
Explanation
Stomatitis refers to the inflammation of the mouth and oral mucosa, which can cause pain and difficulty swallowing. In the context of a client receiving chemotherapy, stomatitis is a common side effect that can occur due to the effects of chemotherapy on rapidly dividing cells, including those in the oral cavity. When a client develops stomatitis, it is important for the practical nurse (PN) to obtain information about the client's ability to swallow during a focused assessment. This is because stomatitis can significantly impact a client's ability to eat and drink comfortably, which can lead to dehydration and malnutrition. Assessing the client's ability to swallow helps determine the extent of the issue and guides appropriate interventions and support.
Let's briefly evaluate the other options:
a) Urinary output.
Urinary output is not directly related to stomatitis. Stomatitis primarily affects the oral cavity, and its impact on urinary output is minimal or nonexistent. While monitoring urinary output is important for assessing hydration status, it is not the priority in this situation.
c) Frequency of bowel movements.
The frequency of bowel movements is unrelated to stomatitis. Stomatitis primarily affects the mouth, and its presence does not directly influence bowel movements. Assessing bowel movements may be relevant for other concerns, but it is not specifically related to stomatitis.
d) Blood pressure while standing.
Blood pressure while standing, also known as orthostatic blood pressure, is not directly relevant to stomatitis. Stomatitis primarily affects the oral cavity and does not typically have a direct impact on blood pressure. Assessing blood pressure while standing may be appropriate for other health concerns, such as orthostatic hypotension, but it is not the priority in this situation.
In summary, when a client receiving chemotherapy develops stomatitis, the practical nurse should focus on assessing the client's ability to swallow as it directly relates to the impact of stomatitis on the client's nutrition and hydration.
Correct Answer is D
Explanation
Choice A rationale:
Checking the client's temperature is important for assessing the client's condition, but it is not a priority before administering penicillin G IV for meningitis.
Choice B rationale:
Assessing the client's level of consciousness is essential for monitoring neurological status, but it is not the highest priority action before administering penicillin G IV for meningitis.
Choice C rationale:
Asking the client about any history of allergies is important for assessing potential allergic reactions to medications. However, the most critical action before administering penicillin G IV for meningitis is to obtain a blood sample for culture and sensitivity. This action helps identify the causative organism and guides appropriate antibiotic therapy, as meningitis can be life-threatening and requires prompt treatment.
Choice D rationale:
Obtaining a blood sample for culture and sensitivity is the highest priority action before administering penicillin G IV for meningitis. Identifying the specific pathogen responsible for the infection is crucial for selecting the most effective antibiotic therapy and preventing complications.
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