A nurse is reviewing a client’s lab results. Two days ago, the hemoglobin was 11.2 g/dL, and today it is 10.4 g/dL. What does this change indicate?
A normal, expected fluctuation in lab values.
The client's fluid status is improving.
The client is at increased risk for hemorrhage.
The client is experiencing a worsening anemic state.
The Correct Answer is D
Choice A rationale
A decrease of 0.8 g/dL in hemoglobin over two days is a significant change, not a normal fluctuation. Normal daily fluctuations are typically less than 0.5 g/dL. This magnitude of change indicates a pathological process, such as blood loss or hemodilution, which requires further investigation to determine the underlying cause.
Choice B rationale
An improvement in fluid status, such as a decrease in hypervolemia, would typically lead to an increase in hemoglobin concentration due to a reduction in the diluting effect of excess plasma volume. A decrease in hemoglobin, as observed here, suggests either blood loss or worsening fluid retention, which dilutes the red blood cell count.
Choice C rationale
While a decrease in hemoglobin can be a sign of hemorrhage, it does not, in itself, directly indicate an increased risk for future hemorrhage. It indicates that blood loss has likely already occurred or that there is an underlying issue causing the decrease. The decrease is a result of a process, not a risk factor for a future event.
Choice D rationale
The decrease in hemoglobin from 11.2 g/dL to 10.4 g/dL over a short period indicates a worsening anemic state. Anemia is a condition characterized by a deficit of red blood cells or hemoglobin. This change suggests that the underlying cause, whether it is blood loss or a physiological process, is worsening and requires intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum, typically caused by birth trauma. It does not involve the brain tissue directly and therefore does not cause brain damage. It is a localized issue outside the skull, not an intracranial hemorrhage.
Choice B rationale
A cephalhematoma is a localized bleeding under the scalp and does not affect the infant's digestive system or suckling reflex. Therefore, a poor appetite is not a direct or common complication of this condition. A neonate's feeding patterns are usually not impacted.
Choice C rationale
A cephalhematoma contains red blood cells that will be reabsorbed and broken down by the infant's system. This process releases a significant amount of bilirubin, which can overwhelm the newborn's immature liver. This leads to hyperbilirubinemia, increasing the risk of jaundice.
Choice D rationale
While some neonates may be at risk for hypoglycemia, there is no direct causal link between a cephalhematoma and low blood glucose levels. Hypoglycemia is more commonly associated with conditions like maternal diabetes or prematurity, not a localized collection of blood on the scalp.
Correct Answer is B
Explanation
Choice A rationale
Allowing a child to choose an injection site may lead to an inappropriate or unsafe location. The ventrogluteal and vastus lateralis muscles are the preferred sites for intramuscular injections in children, selected based on the child's age, muscle development, and the volume of medication. Allowing a child to select an unsafe site could risk nerve or vascular injury.
Choice B rationale
Topical anesthetics, such as lidocaine/prilocaine cream, are effective in reducing the perception of pain associated with injections. They work by blocking sodium channels in neuronal membranes, preventing the propagation of pain signals to the central nervous system. Applying the cream ten minutes before the procedure allows for adequate time for the anesthetic effect to take place.
Choice C rationale
The ventrogluteal site is the preferred site for intramuscular injections in children over seven months old. The nurse should ask the child to lie on their side with the upper knee bent to a 45-degree angle. This position ensures relaxation of the gluteal muscles and allows for accurate landmarking of the greater trochanter, anterior superior iliac spine, and iliac crest, minimizing the risk of sciatic nerve injury.
Choice D rationale
Subcutaneous sites are not typically used for vitamin B12 injections. Subcutaneous injections are given into the fatty tissue below the dermis and are best for small volumes of non-irritating, water-soluble medications, such as insulin. Vitamin B12 is typically administered via the intramuscular route to ensure proper absorption into the muscle tissue.
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