Nokea
Laboratory results
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female:
12-16 g/dL
(120-160 g/L)
5 g/dL
The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.
- A. Coarse crackles
- B. Dyspnea
- C. Pallor
- D. Respiratory depression
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (B), pallor (C), and tachycardia (E) as compensatory mechanisms. Crackles (A) suggest fluid overload, and respiratory depression (D) is unrelated.
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The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
- A. Age of 50
- B. Diagnosis of ovarian cancer
- C. Lying pulse 80/min, standing pulse 110/min
- D. Osteoarthritis of knees
- E. Takes carbidopa/levodopa
- F. Uses a cane to ambulate
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (A) is not a significant risk factor alone, ovarian cancer (B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?
- A. Lochia that soaks a perineal pad every 2 hours
- B. Persistent headache with blurred vision
- C. Red, painful nipple on one breast
- D. Strong-smelling vaginal discharge
Correct Answer: B
Rationale: Headache with blurred vision (B) suggests preeclampsia, a life-threatening condition requiring immediate intervention. Lochia (A), nipple pain (C), and discharge (D) are normal or less urgent postpartum findings.
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.