The nurse is providing care for four patients: Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air; Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L); Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L); and Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L). What action should the nurse take next?
Transfer Patient D to an isolation room 24 hours prior to surgery.
Increase Patient A’s oxygen to 4 L/minute via nasal cannula.
Ensure that there are two units of packed cells available for Patient B.
Request the dietitian to include a banana in Patient C’s breakfast tray.
The Correct Answer is C
Choice A rationale
There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.
Choice B rationale
Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.
Choice C rationale
Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.
Choice D rationale
Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F","H"]
Explanation
H.
Choice A rationale
Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice B rationale
Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.
Choice C rationale
Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.
Choice D rationale
Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.
Choice E rationale
Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.
Choice F rationale
Allowing the client to take a position of comfort can help improve breathing and should be encouraged.
Choice G rationale
Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.
Choice H rationale
Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
The material should not be written at a twelfth-grade reading level. Older adults may have varying levels of literacy, and health information should be accessible to all. It is recommended that patient education materials be written at a sixth-grade reading level or lower.
Choice B rationale
Using a 12-point type font can make the material easier to read, especially for older adults who may have vision problems.
Choice C rationale
Including a list with definitions of unfamiliar terms can help older adults understand the material better. Medical jargon can be confusing, and clear explanations of these terms can improve comprehension.
Choice D rationale
Pictures can help illustrate complex ideas and make the material more engaging and easier to understand. Visual aids can be particularly helpful when explaining how to take medication or demonstrating exercises.
Choice E rationale
Using common words with few syllables can make the material more accessible. Complex medical terms can be confusing, and using simple language can help ensure that the information is understood.
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