A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks:

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for
dropdown
as evidenced by the
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².

Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.

Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.

Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.

Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.

Choice B rationale

Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.

Choice C rationale

Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.

Choice D rationale

Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.

A. Position the patient with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. B. Remove the NG tube if the patient begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Encourage the patient to take sips of water to facilitate the insertion of the NG tube into the esophagus.

Correct Answer is D

Explanation

Choice A rationale

While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.

Choice B rationale

If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.

Choice C rationale

Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.

Choice D rationale

Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.

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A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is placing a patient on isolation precautions. The patient’s diagnostic results at 1400 are given.Which of the following actions should the nurse take?

Correct Answer is ["A","B"]

Explanation

A nurse is caring for a patient who needs a nasogastric (NG) tube for stomach decompression. Which of the following steps should the nurse take when inserting the NG tube?

Correct Answer is D

Explanation

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

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A nurse is providing discharge instructions to a patient who will be using a walker.Which of the following statements by the patient indicates that the teaching has been effective?

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks:

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for
dropdown
as evidenced by the
dropdown
.