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The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.
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When documenting subjective data, the nurse should do which of the following?
- A. Use the client’s own words placed in quotation marks.
- B. Paraphrase the information stated by the client.
- C. Validate the information with the client’s family prior to documentation.
- D. Record the information using nonspecific words.
Correct Answer: A
Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic human needs, is appropriate for what level of needs?
- A. Physiologic
- B. Safety
- C. Love and belonging
- D. Self-actualization
Correct Answer: A
Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs. Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. The nurse should proceed to the diagnosis step of the nursing process after reviewing the patient's data. In this step, the nurse will analyze the information gathered to identify the patient's health problems and needs. Given the patient's lack of voiding, abnormal kidney function, and decreased oral intake, the nurse needs to determine the underlying issues contributing to these findings. This analysis will guide the nurse in developing a plan of care to address the patient's specific health concerns.
Choice B: Planning would be premature without a clear understanding of the patient's health problems, needs, and contributing factors. Choice C: Implementation would involve carrying out interventions without a thorough understanding of the patient's health issues. Choice D: Evaluation comes after the implementation of interventions to assess their effectiveness, which cannot be done without a clear diagnosis.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.
Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.
An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.