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Which client’s laboratory value requires immediate intervention by a nurse?
Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday.

A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L).

A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday.

A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Answer and Explanation

The Correct Answer is C

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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Correct Answer is D

Explanation

Choice A reason: Keeping pressure on the abdomen and coughing is incorrect for diaphragmatic breathing, which enhances lung expansion, not airway clearance. Coughing is for post-drainage. The client’s incorrect technique (abdominal expansion on exhalation) requires correction, as this reverses mechanics, reducing ventilation efficiency in conditions like COPD.

Choice B reason: The client’s technique is incorrect, expanding the abdomen on exhalation, not inhalation, reducing diaphragmatic efficacy. Confirming it as correct is wrong, as it impairs lung expansion. Demonstrating proper technique corrects the error, ensuring effective breathing to improve oxygenation, addressing the physiological need for ventilation.

Choice C reason: Documenting success is inaccurate, as the client’s technique is reversed, expanding the abdomen on exhalation. Diaphragmatic breathing requires inhalation expansion to lower the diaphragm, increasing lung capacity. Correcting the technique via demonstration ensures proper mechanics, not documenting an ineffective method that hinders ventilation.

Choice D reason: Demonstrating proper diaphragmatic breathing corrects the client’s error of exhalation expansion. Inhaling expands the abdomen via diaphragmatic descent, increasing tidal volume; exhaling relaxes it. This optimizes ventilation, addressing the need for effective breathing in conditions requiring enhanced lung function, ensuring the client learns the correct technique.

A. Administer a PRN narcotic. B. Ask the husband to step out. C. Have delivery table set up. D. Notify rapid response team.

Correct Answer is C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

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Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

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Naxlex Comprehensive Predictor Exams

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

Correct Answer is D

Explanation

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

Which client’s laboratory value requires immediate intervention by a nurse?
Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]