Nokea
A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?
- A. 13.0 g/dL
- B. 10.2 g/dL
- C. 5.0 g/dL
- D. 11.4 g/dL
Correct Answer: C
Rationale: The nurse should immediately report a 5.0 g/dL, which is a critical low level. A 13.0 g/dL is a normal level, 11.4 is slightly low, and 10.2 is low.
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When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?
- A. Heart rate of 120 beats/minute
- B. Respiratory rate of 16 breaths/minute
- C. Blood pressure of 140/90 mm Hg
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A rapid pulse rate can indicate reduced erythrocytes or inadequate hemoglobin levels. The respiratory rate for this client is within normal range. Hypertension is not indicative of a low hemoglobin level, and what is usually seen would be hypotension. The oxygen saturation level is within normal range.
A client informs the nurse that he is having a difficult time coping with seasonal allergies and has taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies?
- A. Elevated eosinophils
- B. Elevated basophils
- C. Elevated monocytes
- D. Elevated neutrophils
Correct Answer: A
Rationale: Eosinophils phagocytize foreign material. Their numbers increase in allergies, some dermatologic disorders, and parasitic infections. Basophils are also capable of phagocytosis; they are active in allergic contact dermatitis and some delayed hypersensitivity reactions. Monocytes engulf microbial invaders and display the antigenic surface to T lymphocytes. Neutrophils are a major component of the inflammatory response and defense against bacterial infection.
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?
- A. Platelets
- B. Leukocytes
- C. Erythrocytes
- D. Albumin
Correct Answer: A
Rationale: Platelets participate in clotting blood. Leukocytes protect against infection. Erythrocytes transport oxygen, and albumin affects intravascular osmotic pressure.
A client has type AB blood. What type of blood must this client receive during a blood transfusion?
- A. They can receive blood from persons with any type of blood if the RH factor is compatible.
- B. They can only receive blood from persons with type A blood.
- C. They can only receive blood from persons with type B blood.
- D. They can only receive blood from persons with type O blood if the RH factor is positive.
Correct Answer: A
Rationale: People with type AB blood are considered universal recipients because both A and B antigens are present on the red cell membrane. Clients with type AB blood can receive blood from persons with any type of blood, but the Rh factor must be compatible. The other distractors are incorrect because the client can receive blood from any type.
Macrophages attack and destroy foreign substances to the body. Where does this action occur?
- A. At the site of trauma
- B. In the lymph node
- C. In the vascular system
- D. In the thymus
Correct Answer: B
Rationale: As lymph passes through the node, macrophages attack and engulf foreign substances such as bacteria and viruses, abnormal body cells, and other debris. The other options are incorrect.