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:

Systemic autoimmune vasculopathy is not a typical underlying disease pathology associated with a waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.

Choice B rationale:

Autonomic neuropathy may manifest with a variety of symptoms, including autonomic dysregulation, but it is not a common underlying pathology leading to a waddling gait and frequent falls in a child. This choice is not relevant to the symptoms described.

Choice C rationale:

Impaired neuron function can result in various neurological symptoms, but it does not specifically explain the waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.

Choice D rationale:

Muscle fiber degeneration is the most appropriate explanation for the symptoms of a waddling gait and frequent falls in a 5-year-old child. These symptoms are indicative of a neuromuscular disorder known as Duchenne muscular dystrophy (DMD), which involves progressive muscle weakness and degeneration. DMD is characterized by the loss of muscle fibers and is a common cause of a waddling gait and falls in affected children. Therefore, choice D is the correct answer based on the understanding of the underlying disease pathology.

A. “You may notice that your reaction time is slower than before.”. B. “You may experience some difficulty with learning new things.”. C. “You may have more neurotransmitters in your brain as you age.”. D. “You may lose some of your sense of smell and taste over time.”. E. “You may have more oxygen delivery to your brain cells as you age.”.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.

Choice B rationale:

Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.

Choice C rationale:

This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.

Choice D rationale:

Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.

Choice E rationale:

This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

Correct Answer is D

Explanation

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching?