A nurse is assisting with the care of a client who is admitted to the medical surgical unit.
Complete the following sentences by using the list of options:
The nurse anticipates the client will likely require
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}
The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.
Rationale:
(i)
B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.
(ii)
C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.
F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.
Incorrect:
(i)
A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss
C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.
D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.
E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.
(ii)
A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.
B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.
D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.
E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Put small cushion under the newborn's head for support.":
This statement is incorrect. Placing a small cushion or any additional padding under a newborn’s head in a car seat is not recommended. Extra padding can interfere with the proper fit of the harness and could pose a safety risk in the event of a crash. The car seat should be used as designed, without extra padding that could affect the infant's positioning.
B) "Position the car seat at a 90° angle.":
This statement is incorrect. The car seat should be positioned at a 45-degree angle, not 90 degrees. A 45-degree angle helps prevent the infant’s head from falling forward, which can obstruct the airway and cause breathing difficulties. Positioning the seat at the correct angle ensures that the baby’s head and neck are properly supported.
C) "Place the shoulder harnesses at the level of the infant's shoulders.":
This statement is correct. For optimal safety, the shoulder harness straps should be at or just below the infant's shoulders when they are in a rear-facing car seat. This positioning helps to keep the baby secure and ensures the harness fits properly in the event of an accident. The harness should be snug and positioned correctly to provide the best protection.
D) "Keep the airbag on if the car seat is in the front seat.":
This statement is incorrect. It is recommended that infants and young children always be placed in a rear-facing car seat in the back seat of the vehicle, as this is the safest position. Airbags can be dangerous to infants if the car seat is in the front seat. If the car seat must be placed in the front seat (which is not recommended), the airbag should be turned off to prevent injury in the event of a crash.
Correct Answer is A
Explanation
A) Hot cocoa: Hot cocoa contains the least amount of caffeine compared to the other beverages listed. While it does contain some caffeine, it is significantly lower than coffee, tea, or cola. A typical 8 oz serving of hot cocoa contains approximately 3-10 mg of caffeine, making it the best option for a client looking to reduce caffeine intake.
B) Brewed green tea: Brewed green tea contains more caffeine than hot cocoa. On average, an 8 oz cup of brewed green tea contains about 25-30 mg of caffeine, which is more than cocoa but less than coffee or cola. Although green tea has health benefits, it may not be the best option for those trying to limit caffeine intake.
C) Instant coffee: Instant coffee typically contains more caffeine than brewed green tea or hot cocoa. An 8 oz serving of instant coffee can contain around 30-90 mg of caffeine, depending on the brand and how it is prepared. While it provides a caffeine boost, it is not a good choice for someone seeking to reduce caffeine consumption.
D) Cola soft drink: Cola soft drinks contain a moderate amount of caffeine, usually about 30 mg per 8 oz serving. While this is less than coffee or tea, it still contains more caffeine than hot cocoa and could be a concern for someone trying to cut back on caffeine.
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