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 D
Explanation
A. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).
B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.
C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.
D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.
Correct Answer is D
Explanation
A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.
B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.
C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.
D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.
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