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.

Nursing Test Bank

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Correct Answer is C

Explanation

Rationale

A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.

B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.

C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.

D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.

A. Lung biopsy. B. Antibody testing. C. Sweat test. D. Spirometry.

Correct Answer is D

Explanation

Rationale

A. A. lung biopsy involves obtaining a tissue sample from the lung for microscopic examination. It is typically performed to diagnose conditions such as lung cancer or to investigate unusual findings seen on imaging studies. However, for a client with COPD experiencing increased shortness of breath, a lung biopsy is not typically indicated as a first-line investigation. It is more invasive and usually reserved for specific diagnostic purposes other than routine evaluation of COPD symptoms.

B. Antibody testing is used to detect antibodies specific to certain infections or autoimmune conditions. It is not typically used in the routine evaluation of COPD symptoms unless there is suspicion of a specific autoimmune or infectious cause contributing to exacerbations, which is less common in COPD compared to other conditions.

C. A. sweat test is used to diagnose cystic fibrosis (CF), a genetic disorder that affects the lungs and digestive system. It measures the amount of chloride in sweat, which is elevated in individuals with CF. Since COPD and CF are distinct conditions with different underlying causes and diagnostic criteria, a sweat test is not appropriate for evaluating COPD symptoms.

D. Spirometry is the most appropriate test to schedule for evaluating a client with COPD who reports increased shortness of breath with activity. Spirometry measures lung function by assessing how much and how quickly a person can move air into and out of their lungs. It provides valuable information about the severity of airflow limitation, which is characteristic of COPD.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

Correct Answer is D

Explanation

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?