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 ["1.32"]
Explanation
Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.
Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.
Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.
Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.
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