A nurse is assessing a client who received

2 units of packed RBCs 48 hrs ago. Which

of the following findings should indicate to

the nurse that the therapy has been

effective?

Hemoglobin 14.9 g/dL

The nurse should identify that

packed RBCs a re administered to

clients who have a decreased level

of hemoglobin or hematocrit. This h

emoglobin level is within the

expected reference range of 14 to

18 g/dL for males and 12 to 16 g/dL

for females, indicating the therapy

has been effective.

A nurse working in a n emergency

department is triaging four clients. Which of

the following clients should the nurse

recommend for treatment first?

A middle adult client who has

unstable vital signs.

Using the stable vs unstable

approach t o client care, the nurse

should recommend priority treatment

for the client who has u nstable vital

signs because this client requires

immediate treatment to reduce the

risk of further injury o r possible

death.

A nurse is caring for a c lient who has fluid

volume overload. Which of the following

tasks should the nurse delegate t o the

CNA?

Measure the client’s daily weight

It is within the CNAs range of

function to measure a client’s daily

weight, so the nurse should delegate

this task to them.

A nurse is preparing t o administer mannitol

0.2g/kg IV bolus over 5 min as a test dose

to a client who has severe oliguria. The

client weighs 198lb. What is t he amount in

grams the nurse should administer?

18 g

A nurse is conduction a physical

examination for an adolescent and is

assessing the range of motion of the legs.

W hich of the following images indicates the

adolescent is abducting the hip joint?

In the correct image, the adolescent

is abduction the hip joint by moving

the leg away from the midline of the

body.

A nurse is caring for a c lient who has

hyperthyroidism. Which of the following

findings should the nurse expect?

Tremors

Tremors are a manifestation of

hyperthyroidism, along with

tachycardia, diaphoresis, weight

loss, insomnia, and exophthalmia.

A nurse is assessing a school-aged child

who has bacterial meningitis. Which of the

following findings should the n urse expect?

Nuchal rigidity

This is a manifestation of bacterial

meningitis.

A nurse is assessing a newborn’s heart

rate. Which of the following actions should

the nurse take?

Auscultate the apical pulse at least 1

min.