A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?
Temperature 38.2° C (100.8° F)
Hematocrit 45%
Respiratory rate 12/min
Urine specific gravity 1.015
The Correct Answer is A
A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues
or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This instruction is more appropriate for female clients performing perineal hygiene before providing a clean-catch urine specimen. For straight catheterization, the nurse typically performs sterile technique, including cleansing the urethral meatus with an antiseptic solution as part of the procedure. The client's perineal area may be cleansed if necessary, but the primary focus is on maintaining sterile technique during catheter insertion.
B. When performing straight catheterization, the nurse inserts a sterile catheter into the client's bladder via the urethra to obtain urine directly. The urine is collected from the catheter itself as it drains into a sterile specimen container. It's essential to avoid touching the catheter's port or allowing it to come into contact with non-sterile surfaces to prevent contamination.
C. When inserting a Foley catheter (indwelling catheter), sterile water is used to inflate the balloon at the tip of the catheter after insertion into the bladder. For straight catheterization, a balloon is not typically inflated because the catheter is removed immediately after urine is obtained. Therefore, this step is not applicable in this context.
D. It is crucial to use a sterile specimen container to collect urine obtained via straight catheterization. This ensures that the specimen remains uncontaminated and suitable for culture and sensitivity testing, which requires accurate identification of any bacteria present in the urine.
Correct Answer is A
Explanation
A. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.
C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.
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