A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?.

Cellular hypoxia.

Prolonged bleeding.

Fluid retention.

Impaired immunity.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Hemoglobin of 10 g/dL and hematocrit of 30% are lower than the normal ranges (Hemoglobin: 13.5-17.5 g/dL for men, 12.0-15.5 g/dL for women; Hematocrit: 38.8-50.0% for men, 34.9-44.5% for women). This can lead to cellular hypoxia as there are fewer red blood cells to carry oxygen.
Choice B rationale:
These lab values do not directly indicate a risk for prolonged bleeding.
Choice C rationale:
These lab values do not directly indicate a risk for fluid retention.
Choice D rationale:
While severe anemia can affect the immune response, these values do not directly indicate impaired immunity.

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Correct Answer is D

Explanation

Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.

A. Use alcohol-based hand rubs before administering eye drops for a client. B. Use chlorhexidine to wash hands if the client is immunosuppressed. C. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. D. Keep artificial nails trimmed.

Correct Answer is B

Explanation

Choice A rationale:
Alcohol-based hand rubs are not recommended before administering eye drops as they can cause eye irritation.
Choice B rationale:
Chlorhexidine is recommended for hand hygiene when caring for immunosuppressed clients as it has broad-spectrum antimicrobial activity.
Choice C rationale:
Alcohol-based hand rubs are not effective against Clostridium difficile. Soap and water should be used instead.
Choice D rationale:
Artificial nails can harbor pathogens and are not recommended in healthcare settings.

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A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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