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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: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

A. Take the medication on an empty stomach. B. Report any signs of gastrointestinal bleeding. C. Wear a high intensity sunblock when outside. D. Monitor blood pressure frequently.

Correct Answer is B

Explanation

Choice A reason: Taking ibuprofen on an empty stomach increases gastrointestinal irritation, as NSAIDs inhibit prostaglandins, reducing gastric mucus protection. This risks gastritis or ulcers. Taking it with food minimizes irritation, making this instruction incorrect and potentially harmful for clients managing chronic arthritic pain with ibuprofen.

Choice B reason: Ibuprofen, an NSAID, risks gastrointestinal bleeding by inhibiting prostaglandins, weakening stomach lining protection, and impairing platelet aggregation. Symptoms like black stools or hematemesis indicate serious complications. Reporting these ensures early intervention, preventing severe outcomes like perforation or anemia, making this a critical instruction for safe use.

Choice C reason: High-intensity sunblock is relevant for photosensitizing drugs (e.g., doxycycline), not ibuprofen, which does not significantly increase photosensitivity. NSAIDs primarily affect cyclooxygenase pathways, not skin UV sensitivity. Reporting gastrointestinal bleeding is more critical, as it addresses a common, severe side effect requiring urgent attention.

Choice D reason: Ibuprofen can elevate blood pressure via sodium retention and vasoconstriction, but this is less common at standard doses. Gastrointestinal bleeding is a more frequent, severe risk, as NSAIDs disrupt gastric mucosa. Reporting bleeding symptoms takes precedence to prevent life-threatening complications, making blood pressure monitoring secondary.

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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

Which nursing intervention is most effective in determining the severity of a client’s pain?

Correct Answer is D

Explanation

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

Correct Answer is B

Explanation

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

A client with chronic kidney disease (CKD) is prescribed a low-potassium diet. Which food choice indicates to the nurse that the client understands the dietary restrictions?

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide?

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)]