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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.

B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.

C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.

D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.

A. Putting on sterile gloves after preparing the sterile field B. Placing the supplies on the sterile field and leaving a 1-inch perimeter C. Balancing the bottle on the sterile basin while pouring the liquid D. Applying a sterile gown after applying a sterile mask E. Answer: C.

Correct Answer is C

Explanation

A. Putting on sterile gloves after preparing the sterile field: This is correct aseptic practice, as sterile gloves should be donned after the sterile field is prepared to maintain sterility.

B. Placing the supplies on the sterile field and leaving a 1-inch perimeter: Maintaining a 1-inch border around the sterile field is standard practice to avoid contamination. Supplies placed within the field but outside this border remain sterile.

C. Balancing the bottle on the sterile basin while pouring the liquid: Placing a bottle on a sterile field risks contaminating the field if the bottle is not sterile. This action constitutes a break in surgical aseptic technique.

D. Applying a sterile gown after applying a sterile mask: Donning a mask before the sterile gown is appropriate to prevent contamination of the sterile gown during placement. This does not break aseptic technique.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Correct Answer is C

Explanation

A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?

A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?

A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse make?

Exhibits A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdown as evidenced by the client’s dropdown.

A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?

A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?