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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
- I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
- I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
- I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
- I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
- My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.
Correct Answer is C
Explanation
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
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