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A young adult client, admitted to the emergency department following a motor vehicle collision, is transfused with 4 units of PRBCs. The client's pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all PRBCs have been transfused?
- A. 23%
- B. 25%
- C. 27%
- D. 29%
Correct Answer: D
Rationale: One unit of PRBCs typically raises the hematocrit by 3%. Since the client received 4 units, the hematocrit is expected to increase by approximately 12% (4 units x 3% per unit). Therefore, the nurse should expect the client's hematocrit to be 29% after all PRBCs have been transfused. Choices A, B, and C are incorrect as they do not account for the cumulative effect of multiple PRBC units on the hematocrit level.
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The nurse is caring for a client with acute pancreatitis. Which laboratory result is most indicative of this condition?
- A. Elevated serum amylase
- B. Decreased serum bilirubin
- C. Increased blood urea nitrogen (BUN)
- D. Decreased alkaline phosphatase
Correct Answer: A
Rationale: Elevated serum amylase is the most indicative laboratory result of acute pancreatitis. In this condition, the pancreas becomes inflamed, leading to the leakage of amylase and lipase into the bloodstream. Elevated serum amylase levels are a classic finding in acute pancreatitis. Choices B, C, and D are not typically associated with acute pancreatitis. Decreased serum bilirubin, increased blood urea nitrogen (BUN), and decreased alkaline phosphatase levels are not specific markers for acute pancreatitis.
An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?
- A. Administer a prescribed sedative
- B. Encourage client to drink water
- C. Apply a high flow venturi mask
- D. Assist her to an upright position
Correct Answer: D
Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.
While performing a skin assessment on an older adult, the nurse notices a number of irregular round brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?
- A. Apply a topical antibiotic ointment.
- B. Monitor the lesions for changes.
- C. Advise the client to use sunscreen.
- D. Refer the client for a skin lesion biopsy.
Correct Answer: D
Rationale: Referral for a skin biopsy is necessary to rule out potential malignancy of irregular skin lesions. Applying a topical antibiotic ointment (Choice A) is not indicated for irregular pigmented lesions. Monitoring the lesions for changes (Choice B) may delay appropriate intervention if malignancy is present. Advising the client to use sunscreen (Choice C) is important for sun protection but is not the priority when irregular lesions are present.
A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Evidence of spread of the disease to the kidney.
- B. Confirmation of the autoimmune disease process.
- C. Representative of a decline in the client's condition.
- D. Indication of the onset of joint degeneration.
Correct Answer: B
Rationale: The correct interpretation of elevated serum rheumatoid factor in a client with rheumatoid arthritis is confirmation of the autoimmune disease process. Rheumatoid factor is a marker for autoimmune activity, thus confirming the diagnosis of rheumatoid arthritis. Choice A is incorrect as elevated rheumatoid factor does not specifically indicate spread of the disease to the kidney. Choice C is incorrect as elevated rheumatoid factor does not always represent a decline in the client's condition. Choice D is incorrect as elevated rheumatoid factor is not an indication of the onset of joint degeneration, but rather points towards autoimmune activity.
When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?
- A. Right side-lying
- B. Left side-lying
- C. Prone
- D. Supine
Correct Answer: D
Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.