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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Increasing fluid intake can help replace cerebrospinal fluid lost during a lumbar puncture, which can alleviate a post-lumbar puncture headache.
Choice B rationale:
Elevating the head of the bed can actually worsen a post-lumbar puncture headache by increasing the loss of cerebrospinal fluid.
Choice C rationale:
While pain medication can provide temporary relief, it does not address the underlying cause of the headache.
Choice D rationale:
Darkening the room and closing the door can help reduce sensory stimulation, but it does not directly address the cause of the headache.
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.
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