A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the
following findings should indicate to the nurse that the therapy has been effective?
Answer:
Hemoglobin 14.9 g/dL
The nurse should identify that packed RBCs are administered to clients who
have a decreased level of hemoglobin or hematocrit. This hemoglobin level is
within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL
for females, indicating the therapy has been effective.
A nurse working in an emergency department istriaging four clients. Which of the
followingclients should the nurse recommend for treatment first?
Answer:
Amiddle adult client who has unstable vital signs.
Using the stable vs unstable approach to client care, the nurse should recommend
priority treatment for the client who has unstable vital signs because this client
requires immediate treatment to reduce the risk of further injury or possible
death.
A nurse is caring for a client who hasfluid volume overload. Which of the following
tasksshould the nurse delegate to the CNA?
Answer:
Measure the client’s daily weight
A TIComprehensivePredictor
ATIComprehensivePredictor
It is within the CNAs range of function to measure a client’s daily weight, so the nurse
should delegate this task to them.
A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a
client who has severe oliguria. The client weighs 198lb. What is the amount in grams the
nurse should administer?
Answer:
A TIComprehensivePredictor
ATIComprehensivePredictor
18 g
A nurse is conduction a physical examination for an adolescent and is assessing the range of
motion of the legs. Which of the following imagesindicates the adolescent is abducting the hip
joint?
Answer:
In the correct image, the adolescent is abduction the hip joint by moving the leg away
from the midline of the body.
A nurse is caring for a client who has hyperthyroidism. Which of the following findings
shouldthe nurse expect?
Answer:
Tremors
Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis,
weight loss, insomnia, and exophthalmia.
A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following
findings should the nurse expect?
Answer:
Nuchal rigidity
Thisis a manifestation of bacterial meningitis
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