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

Explanation

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

A. Insert the catheter at a 45-degree angle. B. Position the client’s arm in a dependent position. C. Remove excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

Correct Answer is B

Explanation

Choice A rationale

Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.

Choice B rationale

Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.

Choice C rationale

Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.

Choice D rationale

Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.

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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 caring for a patient who has dementia. What intervention should the nurse take to minimize the risk of injury to the patient?

Correct Answer is A

Explanation

A nurse is preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

Correct Answer is B

Explanation

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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
.