Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


Rationale: The normal level for glycosylated hemoglobin A1c is 4% to 6%. This test measures the amount of glucose that has become permanently bound to the red blood cells (RBCs) from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes because the results are reflective of the blood glucose levels over the preceding 2- to 3-month period.


Test-Taking Strategy: Focus on the strategic word “priority” when answering this question. Familiarity with this test and its significance is needed to answer this question accurately. Remember that the normal level is between 4% and 6%. This will assist in directing you to “measures to prevent hyperglycemia.” Review this test if you had difficulty with this question.


PTS: 1 DIF: Level of Cognitive Ability: Applying REF: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient- centered collaborative care (6th ed.). St. Louis: Saunders. OBJ: Client Needs: Physiological Integrity TOP: Content Area: Nursing Sciences MSC: Integrated Process: Teaching and Learning


MULTIPLE RESPONSE


1. The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following symptoms of a transfusion reaction, if they occur? Select all that apply. 1. Chills 2. Sleepiness 3. Fatigue 4. Chest pain 5. Low back pain 6. Difficulty breathing


ANS: 1, 4, 5, 6


Rationale: The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction.


Test-Taking Strategy: Note that the strategic words in the question are “most important” and “immediately” and focus on the subject, a transfusion reaction. Eliminate “sleepiness” and “fatigue” because they are comparable or alike. Review the signs of a transfusion reaction if you had difficulty with this question.


Saunders Comprehensive Review for the NCLEX-RN Examination Silvestri 5th Edition Test Bank


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