Patient Data
Drag from Word Choices to complete the sentence.
According to the laboratory values, the client has
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"A","dropdown-group-3":"E"}
Rationale for correct choices:
• Anemia: The client’s hemoglobin (9.3 g/dL) and hematocrit (30%) are both below normal, which indicates a reduced oxygen-carrying capacity of the blood, consistent with anemia.
• Blood loss: The abdominal hematoma, distension, and need for fluid bolus suggest internal bleeding after trauma, leading to a significant drop in hemoglobin and hematocrit.
• Hemodilution from intravenous fluids: The client received large volumes of IV fluids (bolus and maintenance infusion), which dilute circulating red blood cells, worsening the anemia picture.
Rationale for incorrect choices:
• Acidosis: No arterial blood gas (ABG) results are available yet, so there is no evidence to confirm a metabolic or respiratory acidosis at this stage.
• Hypovolemia: The client initially showed low blood pressure and tachycardia, but stabilization with fluids improved her vitals; the lab values specifically indicate anemia, not pure hypovolemia.
• Disseminated intravascular coagulation: PT and PTT are within normal limits, with no signs of uncontrolled clotting or bleeding, so DIC is not supported.
• Rh factor sensitization: The client is B+, but there is no mention of pregnancy or transfusion reactions that would trigger Rh-related hemolysis.
• Pregnancy: No history, findings, or labs indicate pregnancy, so this option is unrelated to the client’s current trauma and blood results.
• Hypoxia: Oxygen saturation remains 98–100% on mechanical ventilation, showing adequate oxygenation despite anemia.
• Blood administration: While the client may need transfusion, labs reflect anemia caused by blood loss and hemodilution, not from receiving blood products.
• Immune response: There are no clinical or laboratory findings of immune-mediated destruction of red cells or inflammation causing the anemia.
• Clotting cascade: Normal PT and PTT show the coagulation pathway is intact, ruling out clotting disorders as the cause of low hemoglobin and hematocrit.
• Hypoventilation: The client is mechanically ventilated with normal oxygenation, and there is no evidence of hypoventilation contributing to her anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Green leafy vegetables: While nutritious and high in vitamins and minerals, green leafy vegetables do not specifically counteract the gastrointestinal effects of antibiotics like cefdinir. They are not directly relevant to maintaining gut flora during antibiotic therapy.
B. Avocados and cheese: These foods provide healthy fats and protein but do not restore beneficial gut bacteria disrupted by antibiotics. They are nutritious but not the primary dietary focus for this purpose.
C. Yogurt or buttermilk: Probiotic-rich foods like yogurt or buttermilk help maintain normal gastrointestinal flora, reducing the risk of antibiotic-associated diarrhea and promoting gut health during cefdinir therapy. Including these foods supports the client’s digestive system while on antibiotics.
D. Fresh fruits: Fruits are rich in vitamins and fiber but do not specifically replace beneficial bacteria lost during antibiotic therapy. They are supportive nutritionally but do not directly prevent gastrointestinal side effects.
Correct Answer is A
Explanation
A. Providing data on the abdomen, bowel sounds, and surgical dressing is the priority during a transfer report. An exploratory laparotomy involves a large incision, making the assessment of evisceration or internal bleeding a critical safety requirement. Absent bowel sounds are an expected finding immediately following abdominal surgery due to anesthesia and bowel manipulation. The receiving nurse must know the initial state of the dressing to monitor for any new sanguineous drainage.
B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.
C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.
D.A history of vomiting prior to surgery is part of the preoperative record and should already be documented in the client's medical history. While relevant for fluid balance, the transfer report should focus on the post-surgical recovery phase and current status. The PACU nurse must prioritize the acute results of the procedure over historical data from three days ago. Current ondansetron administration is more relevant for managing active postoperative nausea.
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