The nurse is caring for four clients:

Client A, who has emphysema and whose oxygen saturation is 94% on room air;

Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L);

Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L);

Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 109/L).

Which intervention should the nurse implement?Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

White Blood Cell [5,000 to 10,000/mm3 (5 to 10 x 109/L)]

Move Client D into an isolation room 24 hours before surgery.

Verify that Client B has two units of packed cells available.

Ask the dietitian to add a banana to Client C's breakfast tray.

Increase Client A's oxygen to 4 L/minute via nasal cannula.

Answer and Explanation

The Correct Answer is B

Rationale

A. Client A's oxygen saturation is acceptable for someone with emphysema.

B. This is because Client B's postoperative hemoglobin level is 8.2 mg/dL, which is significantly lower than the normal reference range of 14 to 18 g/dL. This indicates that Client B is anemic and may require a blood transfusion to increase the hemoglobin level.

C. Client C's potassium level is within the normal range

D. Client D's WBC count is elevated, moving them into isolation is not indicated solely based on an elevated WBC count.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Rationale

A. Herpes simplex virus type II (HSV-II) primarily spreads through direct contact with the lesions and is not airborne. Airborne precautions and negative airflow rooms are not necessary for this condition.

B. Scarlet fever is caused by Group A Streptococcus bacteria and typically spreads through respiratory droplets. However, scarlet fever itself does not require airborne precautions. If complicated with pneumonia, respiratory droplets could potentially spread the infection, but specific airborne precautions are generally not required unless there are other pathogens involved that require it.

C. Scabies is caused by the Sarcoptes scabiei mite and spreads through direct skin-to-skin contact. It does not require airborne precautions or negative airflow rooms.

D. Apositive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) suggest tuberculosis (TB) infection. TB is spread through airborne droplets (e.g., coughing, sneezing), and therefore, requires airborne precautions including negative airflow rooms to prevent transmission to others.A

A. Ask the parent to decrease the infant's intake of fruits for 24 hours. B. Instruct the parent to change the child's diaper more often. C. Encourage the parent to apply lotion with each diaper change. D. Tell the parent to cleanse with soap and water at each diaper change.

Correct Answer is B

Explanation

Rationale

A. Fruits can sometimes increase stool acidity or frequency in infants, potentially aggravating diaper rash. However, unless there is a clear association between fruit intake and exacerbation of symptoms, restricting fruits for 24 hours may not directly address the current rash. It's more important to focus on topical care and diaper hygiene.

B. Changing diapers frequently helps keep the skin dry and reduces exposure to irritants like urine and stool. This intervention is crucial as prolonged exposure to moisture can contribute to diaper rash development and exacerbation.

C. Applying a barrier cream or diaper rash ointment can protect the skin from moisture and irritants, providing a protective layer that promotes healing. This intervention helps soothe the skin and prevent further irritation.

D. Using soap and water at every diaper change can be harsh on the delicate skin of infants, especially if the soap is not pH-balanced or contains fragrances. Plain water or a gentle, pH-balanced cleanser is preferable to avoid further irritation.

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Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is D

Explanation

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

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A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

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While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?