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Exhibits

Click to highlight the findings that indicate an improvement in the client’s condition

Laboratory Results

1800:

WBC count 6,700/mm3 (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18

Temperature 37.5(99.5° F)

WBC count 6,700/mm3 (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18

Temperature 37.5(99.5° F)

Answer and Explanation

The Correct Answer is ["B","C","D","E"]

Rationale for correct choices:

Hemoglobin 12 g/dL: The increase from 9.1 g/dL to 12 g/dL indicates that the client’s anemia is resolving. This suggests effective treatment or stabilization following blood loss, improving oxygen-carrying capacity and overall perfusion.
Hematocrit 36%: The rise from 27% to 36% reflects an improvement in the proportion of red blood cells in circulation. This correlates with better tissue oxygenation and a positive response to interventions such as a blood transfusion.
Blood pressure 112/74 mm Hg: The increase from 90/50 mm Hg indicates improved hemodynamic stability. This suggests the client is no longer hypovolemic and is better able to maintain adequate perfusion to vital organs.
Heart rate 95/min: The decrease from 118/min shows a reduction in compensatory tachycardia. This reflects improved circulatory status and decreased physiological stress following stabilization of blood volume and oxygenation.

Rationale for incorrect choices:

WBC count 6,700/mm³: The WBC count remains unchanged from admission. While within normal limits, it does not specifically indicate improvement in anemia or hemodynamic status, which are the primary concerns in this scenario.
Respiratory rate 18/min: The respiratory rate is unchanged and within normal limits. Although stable, it does not provide a direct measure of improvement in anemia or perfusion.
Temperature 37.5°C (99.5°F): The temperature is stable but slightly elevated. While not concerning, it does not reflect a specific improvement in the client’s primary condition.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Atrial fibrillation: This dysrhythmia is characterized by an irregularly irregular rhythm with absent or unidentifiable P waves, not a prolonged constant P-R interval.

B. Premature atrial complexes: PACs involve early P waves that may have a normal or slightly different P-R interval, but they do not cause a consistently prolonged P-R interval across all beats.

C. First-degree atrioventricular block: A constant P-R interval greater than 0.20 seconds indicates a first-degree AV block. The atrial impulses are delayed at the AV node, but all impulses are conducted to the ventricles, producing a regular rhythm with prolonged P-R intervals.

D. Complete heart block: In complete heart block (third-degree AV block), there is no relationship between P waves and QRS complexes. The P-R interval is variable, unlike the constant prolongation seen in first-degree AV block.

A. Documenting communication with a provider in the progress notes of the client's medical record. B. Placing a yellow bracelet on a client who is at risk for falls. C. Administering potassium via iv bolus. D. Leaving a nasogastric tube clamped after administering oral medication.

Correct Answer is C

Explanation

A. Documenting communication with a provider in the progress notes of the client's medical record: Proper documentation of provider communication is standard nursing practice and does not constitute malpractice. It helps ensure continuity of care and legal protection.

B. Placing a yellow bracelet on a client who is at risk for falls: Implementing fall precautions, such as using a yellow wristband, is an appropriate safety measure and standard of care, not malpractice.

C. Administering potassium via IV bolus: Administering potassium as a rapid IV push is extremely dangerous and can cause cardiac arrest. This action violates the standard of care and constitutes malpractice due to potential harm to the client.

D. Leaving a nasogastric tube clamped after administering oral medication: A nasogastric (NG) tube is often clamped for a short period after administering medication to allow the medication to be absorbed. The nurse's action would only be considered negligent if they left the tube clamped for a prolonged period.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?

Correct Answer is C

Explanation

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

Correct Answer is C

Explanation

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?

Which of the following clients should be considered a priority for immediate assessment and intervention?

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A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client. Which of the following actions should the nurse take first?

A nurse is caring for a client who had a stroke and is having difficulty swallowing. Which of the following referrals should the nurse make for the client?

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following statements should the charge nurse include?

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