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Questions 164

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Extract:

Laboratory results
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)

Female:
12-16 g/dL
(120-160 g/L)

5 g/dL


Question 1 of 5

The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.

Correct Answer: B,C,E

Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (
B), pallor (
C), and tachycardia (E) as compensatory mechanisms. Crackles (
A) suggest fluid overload, and respiratory depression (
D) is unrelated.

Extract:


Question 2 of 5

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

Correct Answer: A,C

Rationale: A tourniquet left on too long (
A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (
C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (
B) can cause hemolysis, and the ventral wrist (
D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.

Question 3 of 5

The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased

Correct Answer: A

Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (
A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (
B), anxiety (
C), or heart rate (
D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.

Question 4 of 5

The nurse is to change a dressing. Which is essential to do when opening the dressing set?

Correct Answer: A

Rationale: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.

Question 5 of 5

The nurse is planning care for all of the following clients. Which client should be cared for first?

Correct Answer: B

Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.

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