A nurse is assisting with the care of a client.
The laboratory results indicate abnormalities.
Which of the following actions should the nurse take?

Place the client on NPO status.

Administer a prescribed medication.

Monitor the client for signs of dehydration.

Encourage oral fluid intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Placing the client on NPO status is required for some specific conditions, such as prior to surgery or when there is risk of aspiration. However, this should not be the first action unless the abnormalities clearly indicate such a need. Monitoring the client’s overall condition should take precedence.

Choice B rationale

Administering a prescribed medication could be helpful depending on the specific abnormality. However, this action depends on the nature of the abnormality and medical orders. It is not the initial step unless a clear order has been provided for a specific issue.

Choice C rationale

Monitoring for signs of dehydration is critical, as dehydration can exacerbate the abnormalities and negatively impact homeostasis. Ensuring the client’s condition does not worsen is a priority, as hydration status often affects laboratory values and overall well-being.

Choice D rationale

Encouraging oral fluid intake is important to prevent or correct dehydration, particularly if lab abnormalities suggest volume depletion. However, it is not the first step. Initial monitoring is required to guide further interventions like fluid intake recommendations.

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Correct Answer is C

Explanation

Choice A rationale

Obtaining a radial pulse is not the next priority for managing a bleeding site in hemophilia. Hemophilia is characterized by clotting factor deficiencies, so the priority is to stop bleeding first. Assessing a pulse does not address active bleeding and can delay essential interventions, such as applying pressure to control hemorrhage.

Choice B rationale

Reinforcing the dressing does not actively address ongoing bleeding in a hemophilia client. Adding more material over the wound may conceal continued bleeding but does not provide the hemostatic effect required to stop it. Direct pressure is necessary for clot formation, which is hindered in hemophilia.

Choice C rationale

Maintaining direct pressure is crucial as it compresses blood vessels, promoting clot formation at the bleeding site. Hemophilia impairs the intrinsic clotting pathway; therefore, mechanical compression compensates for clotting factor deficiencies until further interventions, such as clotting factor infusion, are possible.

Choice D rationale

Checking whether the bleeding has stopped is important, but it should only occur after applying adequate pressure to the site. Hemophilia requires prompt mechanical hemostasis, and delaying pressure to assess cessation risks prolonged bleeding and increased blood loss.

A. Eat two servings of fruit and vegetables per day. B. Limit intake of red and processed meats. C. Limit intake of whole-grain foods. D. Eat fatty fish once per week.

Correct Answer is B

Explanation

Choice A rationale

Two servings of fruits and vegetables per day do not provide sufficient phytochemicals, fiber, and antioxidants necessary for effective cancer risk reduction. Current guidelines recommend five or more servings per day for optimal benefit in reducing cancer risk.

Choice B rationale

Red and processed meats contain nitrates and nitrites that can convert into carcinogenic compounds like nitrosamines during digestion. Limiting their intake reduces the exposure to these harmful compounds, thereby lowering the risk of certain cancers, such as colorectal cancer.

Choice C rationale

Whole-grain foods are rich in dietary fiber, which aids in the removal of carcinogens from the gastrointestinal tract. Limiting their intake contradicts guidelines that emphasize increasing whole-grain consumption for cancer prevention and overall health.

Choice D rationale

Fatty fish is rich in omega-3 fatty acids, which have anti-inflammatory properties. However, eating it once per week does not provide sufficient quantities to significantly impact cancer prevention. The recommendation is to consume fatty fish multiple times per week for health benefits.

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A nurse is assisting with the care of a client.The laboratory results indicate abnormalities.Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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A nurse is assisting with the care of a client.
The laboratory results indicate abnormalities.
Which of the following actions should the nurse take?