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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Sour cream is a dairy product, providing protein. This option provides protein from the sour cream, which is suitable for a vegetarian who consumes dairy products.
B. Fruits and vegetables generally do not provide significant protein. While fruits and vegetables are nutritious, they do not provide sufficient protein for a meal, especially for someone who is vegetarian and needs adequate protein sources.
C. Cream cheese is a dairy product that provides protein. This option also provides protein from the cream cheese, which is suitable for a vegetarian who consumes dairy products.
D. Peanut butter is a plant-based protein source and enriched bread provides carbohydrates. Peanut butter is a good source of protein for vegetarians and is a suitable option for the adolescent client who does not like beans.

A. Muscle hypotonicity B. Positive Chvostek's sign C. Diarrhea D. Tachycardia

Correct Answer is D

Explanation

A. Hypercalcemia can lead to muscle weakness and fatigue rather than hypotonicity. High calcium levels affect neuromuscular function, potentially causing muscle weakness and decreased muscle tone rather than increased flaccidity.
B. Chvostek's sign is a clinical sign of hypocalcemia, not hypercalcemia. It is characterized by facial muscle twitching in response to tapping the facial nerve just anterior to the ear. Therefore, a positive Chvostek's sign would not be expected in hypercalcemia.
C. Hypercalcemia can cause gastrointestinal disturbances such as constipation rather than diarrhea. High calcium levels can lead to decreased smooth muscle contractility in the intestines, resulting in constipation rather than increased motility leading to diarrhea.
D. Hypercalcemia can lead to a variety of cardiovascular effects, including arrhythmias. Tachycardia can occur as a result of increased sensitivity of the heart to catecholamines and altered electrical conductivity in hypercalcemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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