The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; 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); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm (14 x 10^9/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 [5000 to 10,000/mm² (5 to 10 x 10^9/L)].
Move Client D into an isolation room 24 hours before surgery.
Ask the dietitian to add a banana to Client C's breakfast tray.
Increase Client A's oxygen to 4 liters a minute per cannula.
Verify that Client B has two units of packed cells available.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.
Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.
Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.
Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.
Choice B rationale:
Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.
Choice C rationale:
Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.
Choice D rationale:
Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.
Correct Answer is D
Explanation
This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
a) Serum calcium
This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be affected by kidney disease, but it is not a reliable indicator of nephrotoxicity.
b) Hemoglobin and hematocrit
This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.
Hemoglobin and hematocrit may be affected by kidney disease, but they are not reliable indicators of
nephrotoxicity.
c) White blood cell count (WBC)
This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inflammation, but it is not a reliable indicator of nephrotoxicity.
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