A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?
Digoxin 1.0 ng/mL.
WBC 6,000/mm³.
Platelets 100,000/mm³.
Serum potassium 4.0 mEq/L.
The Correct Answer is C
Choice A rationale:
Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.
Choice B rationale:
A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.
Choice C rationale:
Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.
Choice D rationale:
A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.
Choice A rationale:
Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.
Choice B rationale:
Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.
Choice C rationale:
Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.
Choice D rationale:
Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.
Correct Answer is C
Explanation
Choice A rationale:
Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.
Choice B rationale:
A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.
Choice C rationale:
Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.
Choice D rationale:
A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.
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