Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?

Correct Answer: B

Rationale: Hemolytic anemias are characterized by the premature destruction of red blood cells. As a result, the lab values typically seen in hemolytic anemia include decreased red blood cell counts (RBC), increased bilirubin (due to the breakdown of red blood cells), decreased hemoglobin (Hgb) and hematocrit (Hct) levels, and increased reticulocytes (immature red blood cells released from the bone marrow in response to the increased demand for red blood cell production). Therefore, profile B aligns with the expected lab values consistent with hemolytic anemia.

Correct Answer: A

Rationale: After a cardiac catheterization, the nurse should be assessing for the development of cardiac arrhythmias, as this is a potential complication associated with the procedure. Cardiac arrhythmias can occur due to irritation of the heart during the catheterization, changes in electrolyte levels, or other factors related to the procedure. Monitoring the child's cardiac rhythm closely allows for early detection and management of arrhythmias to prevent serious complications. While other complications such as hypostatic pneumonia, heart failure, and rapidly increasing blood pressure can also occur, cardiac arrhythmia is the most important complication to assess for immediately post-cardiac catheterization.

Correct Answer: D

Rationale: The nurse would use the whisper voice test as an initial screening test to determine hearing loss. This test involves the nurse whispering a series of words or numbers from a distance behind the patient to assess their ability to hear and repeat the whispered words accurately. This test is quick, easy, and can be performed in a quiet environment without the need for special equipment, making it an effective initial screening tool for hearing loss. The Romberg test assesses balance, the caloric test evaluates vestibular function, and the otoscopic examination is used to assess the external ear canal and eardrum, but none of these tests specifically assess hearing loss.

Correct Answer: C

Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.

Correct Answer: B

Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.