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. Encourage the client to soak in a hot bath.: While a warm bath can help alleviate muscle tension and discomfort, it is not recommended during the latent phase of labor due to the potential for increasing the risk of infection, especially if the membranes are ruptured.
B. Instruct the client to change positions frequently.: Frequent position changes during the latent stage of labor can help alleviate pelvic pain, improve comfort, and encourage progress in labor. This is a beneficial intervention that promotes movement and comfort without introducing unnecessary risks.
C. Apply fundal pressure during contractions.: Fundal pressure is not appropriate during the latent stage of labor, as it can cause fetal distress or other complications. It is typically avoided unless indicated in more advanced stages of labor under specific circumstances.
D. Tell the client to push during contractions.: Pushing is not recommended during the latent stage of labor. The latent phase involves the cervix gradually dilating, and pushing should be delayed until the active stage of labor when the cervix is fully dilated and ready for delivery.
Correct Answer is C
Explanation
A. Assist the client into a supine position is incorrect. A supine position can reduce uterine blood flow and may lead to hypotension. The nurse should assist the client into a left-lateral position for optimal results during a nonstress test.
B. Explain that nonreactivity might require immediate medication administration is incorrect. Nonreactivity can indicate fetal distress, but it does not necessarily require medication immediately. Further testing or evaluation would be needed first.
C. Remind the client to press the button when she feels fetal movement is correct. The purpose of the nonstress test is to monitor fetal heart rate acceleration in response to movement. The client is typically instructed to press a button when she feels fetal movement so the nurse can correlate it with fetal heart rate patterns.
D. Tell the client the test should take about 10 min is incorrect. The nonstress test typically takes 20–40 minutes, depending on fetal activity and the need for monitoring.
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