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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.

Choice B rationale:

This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.

Choice C rationale:

This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.

Choice D rationale:

This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.

A. Nausea. B. Fatigue. C. Pain when eating. D. Altered taste sensation.

Correct Answer is C

Explanation

Choice A rationale:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks a nurse about the differences between major depressive disorder (MDD) and dysthymia. Which of the following responses by the nurse is accurate?

Correct Answer is D

Explanation

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

Correct Answer is C

Explanation

A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).

During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement?

The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.).

A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement?

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?