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Questions 164

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Extract:

Laboratory reference ranges
WBCs
5000–10,000/mm3
(5–10 × 109/L)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)

Female: 12.0–16.0 g/dL
(120–160 g/L)


Question 1 of 5

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.

Correct Answer: B,D,E

Rationale: Medication error , failure to report hemoglobin , and failure to notify about blood culture are reportable adverse events. Sepsis death and vaccine refusal are not necessarily preventable errors.

Extract:


Question 2 of 5

The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, HPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?

Correct Answer: A

Rationale: The majority of reactions occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.

Question 3 of 5

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?

Correct Answer: D

Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.

Question 4 of 5

A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to

Correct Answer: D

Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.

Question 5 of 5

A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

Correct Answer: D

Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.

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