A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
BUN 18 mg/dL
Serum creatinine 1.0 mg/dL
Urine output 12 mL/hr
Urine specific gravity 1.020
The Correct Answer is C
A. BUN 18 mg/dL is incorrect. A BUN (blood urea nitrogen) level of 18 mg/dL is within the normal range (typically 7–20 mg/dL) and does not indicate immediate concern in this context. An elevated BUN could indicate dehydration, but this level is not significantly elevated.
B. Serum creatinine 1.0 mg/dL is incorrect. Serum creatinine levels are also within normal limits for most adults, which is around 0.6–1.2 mg/dL, and this finding does not indicate a problem.
C. Urine output 12 mL/hr is correct. A urine output of 12 mL/hr is low and indicates oliguria, which is a concern in the context of dehydration. The normal urine output for an adult is at least 30 mL/hr. A decrease in urine output suggests that the kidneys are not receiving adequate blood flow, which could indicate severe dehydration and requires immediate attention from the provider.
D. Urine specific gravity 1.020 is incorrect. Urine specific gravity of 1.020 is within the normal range (typically 1.005–1.030) and indicates that the kidneys are concentrating urine appropriately, which is not a concerning finding in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'm going to contact your family so they can be with you.": While involving family is important, the nurse should first provide emotional support to the client. It may feel abrupt to the client if the nurse immediately redirects the focus to others without acknowledging the client's current emotional state.
B. "I will stay with you for a while.": This is correct. Offering presence and emotional support by staying with the client is an appropriate response. It shows empathy and provides the client with comfort in a time of emotional distress.
C. "I'm sorry you have to deal with this.": This is less supportive. While it acknowledges the difficulty of the situation, it could unintentionally invalidate the client’s feelings by focusing on the nurse’s perspective rather than the client's experience.
D. "When you feel better, we'll talk about your treatment options.": This is not an appropriate response. It minimizes the client’s current emotional needs and may make the client feel that their feelings are not being prioritized. The focus should be on emotional support first.
Correct Answer is C
Explanation
A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.
B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.
C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.
D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.
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