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Which client’s laboratory value requires immediate intervention by a nurse?
Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday.

A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L).

A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday.

A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Answer and Explanation

The Correct Answer is C

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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Correct Answer is B

Explanation

Choice A reason: Using a heating pad is contraindicated in Raynaud’s, as reduced sensation from vasospasm risks burns. Raynaud’s involves cold-triggered arteriolar constriction, reducing blood flow. Heat does not address vasospasm’s pathophysiology and may cause tissue damage, making this instruction inappropriate compared to cold protection strategies.

Choice B reason: Wearing gloves when handling cold items prevents vasospasm in Raynaud’s, where cold triggers arteriolar constriction, causing ischemia and pain. Protecting extremities maintains blood flow, preventing episodes. This directly addresses the disease’s pathophysiological trigger, making it the most effective instruction for managing Raynaud’s symptoms.

Choice C reason: Knee-high support stockings improve venous return, relevant for venous insufficiency, not Raynaud’s arterial vasospasm. Stockings do not prevent cold-induced vasoconstriction, the primary trigger. Gloves for cold exposure directly mitigate vasospastic episodes, making this instruction less effective for Raynaud’s disease management.

Choice D reason: Regular walking improves overall circulation but does not prevent Raynaud’s vasospastic episodes, triggered by cold or stress. While exercise supports vascular health, avoiding cold exposure with gloves is more targeted, directly reducing arteriolar constriction and ischemic symptoms, making walking a secondary recommendation.

A. Show the client how to clean the walls. B. Assist the client to clean the walls. C. Escort the client out of the bathroom. D. Explain that feces belong in the toilet.

Correct Answer is C

Explanation

Choice A reason: Showing the client how to clean assumes cognitive capacity impaired in schizophrenia, where psychosis or disorganized thinking drives behaviors like fecal smearing. This may reflect delusions, not a lack of cleaning knowledge. Escorting the client out prioritizes hygiene and safety, allowing psychiatric assessment over teaching in an acute situation.

Choice B reason: Assisting with cleaning risks reinforcing the behavior and exposes both to pathogens like E. coli in feces. Schizophrenia may impair compliance or understanding. Escorting the client out ensures safety and hygiene, enabling evaluation of psychotic triggers, making this less appropriate than removing the client from the situation.

Choice C reason: Escorting the client out prevents further pathogen exposure, as feces carry infection risks (e.g., gastroenteritis). In schizophrenia, smearing may stem from psychosis, requiring psychiatric evaluation. This action ensures hygiene and safety, allowing assessment of underlying mental health issues, addressing the behavior’s root cause effectively.

Choice D reason: Explaining that feces belong in the toilet assumes rational understanding, impaired in schizophrenia due to disorganized thought or delusions. This behavior likely reflects psychosis. Escorting the client out prioritizes hygiene and safety, followed by psychiatric intervention, making explanation less effective than immediate removal from the contaminated area.

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Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

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Naxlex Comprehensive Predictor Exams

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

Correct Answer is B

Explanation

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

Correct Answer is C

Explanation

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Which client’s laboratory value requires immediate intervention by a nurse?
Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]