A young adult client, admitted to the emergency department following a motor vehicle collision is receiving
transfusion of 4 units of packed red blood cells (PRBC). The client's pretransfusion hematocrit is 17% (0.17
volume). How many hematocrit value should the nurse expect the client to have after all of the PRBCs have
been transfused
Reference Range:
Hematocrit (42% to 52% (0.4Lto 0.52 volume fraction)]
A 9% (0.09 volume fraction).
B 39% (0.39 volume fraction).
C 19% (0.19 volume traction)
D 29% (0.29 volume fraction).
D 29% (0.29 volume fraction).
,A female client on a psychiatric unit is sweating profusely while she vigorously does push- ups and then runs
the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up,
she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance,
the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these
observations?
• A Disturbed personal identity related to grandiosity.
• B Risk for activity intolerance related to hyperactivity.
• C Risk for other related violence related to disruptive behavior.
• D Deficient diversional activity related to excess energy level.
• C Risk for other related violence related to disruptive behavior.
The antitubular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness
of this medication, which outcome can the nurse expect this client to exhibit?
A Decreased appetite and weight loss.
B A positive sputum smear and culture.
C Decreased cough and sputum.
D Vertigo and tinnitus.
C Decreased cough and sputum.
,5 The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires the nurse to
intervene?
• A Crying for more than 10 minutes.
• B Acrocyanosis with hands and feet cool to touch.
• C Respiratory rate of 73 breaths/minute.
• D No voiding or stooling since birth.
• C Respiratory rate of 73 breaths/minute.
→ infant is hyperventilating; should be 30-60 breaths/min
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory
infection. Which assessment finding warrants immediate intervention by the nurse?
• A Diminished lung sounds.
• B Generalized weakness.
• C Elevated temperature.
• D Pain when swallowing.
• A Diminished lung sounds.
, A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken.
The client's death is imminent and the family is in the client's room. The client is currently exhibiting Cheyne-
Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?
• A Allow privacy for the family and client to express their feelings to one another.
• B. Elevate the head of the client's bed and apply oxygen using a face mask.
• C Apply an automatic blood pressure cuff and take readings every 15 minutes.
• D Teach the client's family how to use an oral suction device to clear the airway.
• A Allow privacy for the family and client to express their feelings to one another.
A client with cirrhosis has ascites and reports feeling short of breath. The client is in a Semi-Fowler's position
with arms posit Which action should the nurse implement?
A Reposition the client in a side-lying position and support his abdomen with pillows.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
C Place the client in a shock position and monitor his vital signs at frequent intervals.
D. Elevate the client's feet on a pillow while keeping the head of the bed elevated.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
transfusion of 4 units of packed red blood cells (PRBC). The client's pretransfusion hematocrit is 17% (0.17
volume). How many hematocrit value should the nurse expect the client to have after all of the PRBCs have
been transfused
Reference Range:
Hematocrit (42% to 52% (0.4Lto 0.52 volume fraction)]
A 9% (0.09 volume fraction).
B 39% (0.39 volume fraction).
C 19% (0.19 volume traction)
D 29% (0.29 volume fraction).
D 29% (0.29 volume fraction).
,A female client on a psychiatric unit is sweating profusely while she vigorously does push- ups and then runs
the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up,
she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance,
the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these
observations?
• A Disturbed personal identity related to grandiosity.
• B Risk for activity intolerance related to hyperactivity.
• C Risk for other related violence related to disruptive behavior.
• D Deficient diversional activity related to excess energy level.
• C Risk for other related violence related to disruptive behavior.
The antitubular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness
of this medication, which outcome can the nurse expect this client to exhibit?
A Decreased appetite and weight loss.
B A positive sputum smear and culture.
C Decreased cough and sputum.
D Vertigo and tinnitus.
C Decreased cough and sputum.
,5 The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires the nurse to
intervene?
• A Crying for more than 10 minutes.
• B Acrocyanosis with hands and feet cool to touch.
• C Respiratory rate of 73 breaths/minute.
• D No voiding or stooling since birth.
• C Respiratory rate of 73 breaths/minute.
→ infant is hyperventilating; should be 30-60 breaths/min
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory
infection. Which assessment finding warrants immediate intervention by the nurse?
• A Diminished lung sounds.
• B Generalized weakness.
• C Elevated temperature.
• D Pain when swallowing.
• A Diminished lung sounds.
, A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken.
The client's death is imminent and the family is in the client's room. The client is currently exhibiting Cheyne-
Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?
• A Allow privacy for the family and client to express their feelings to one another.
• B. Elevate the head of the client's bed and apply oxygen using a face mask.
• C Apply an automatic blood pressure cuff and take readings every 15 minutes.
• D Teach the client's family how to use an oral suction device to clear the airway.
• A Allow privacy for the family and client to express their feelings to one another.
A client with cirrhosis has ascites and reports feeling short of breath. The client is in a Semi-Fowler's position
with arms posit Which action should the nurse implement?
A Reposition the client in a side-lying position and support his abdomen with pillows.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
C Place the client in a shock position and monitor his vital signs at frequent intervals.
D. Elevate the client's feet on a pillow while keeping the head of the bed elevated.
B Raise the head of the bed to a Fowler's position and support his arms with a pillow.
