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 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.
Correct Answer is B
Explanation
A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.
B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.
C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.
D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.
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