A nurse is caring for a client who has malnutrition. Which of the following findings should the nurse report to the provider?
BMI of 18.5
Potassium 3.7 mEq/L
Phosphorus 3.5 mg/dL
Albumin 2.5 g/dL
The Correct Answer is D
Choice A reason: BMI of 18.5 is at the lower end of the normal range (18.5-24.9), but it does not indicate severe malnutrition.
Choice B reason: Potassium 3.7 mEq/L is within the normal range (3.5-5.0), and it does not indicate electrolyte imbalance due to malnutrition.
Choice C reason: Phosphorus 3.5 mg/dL is within the normal range (2.5-4.5), and it does not indicate mineral deficiency due to malnutrition.
Choice D reason: Albumin 2.5 g/dL is below the normal range (3.5-5.0), and it indicates protein deficiency due to malnutrition. Albumin is a major protein in blood plasma that helps maintain fluid balance, transport hormones, and fight infections. Low albumin levels can cause edema, weakness, infection, and poor wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
Correct Answer is C
Explanation
Choice A reason: Dilute formula with 1 tablespoon of water is not a correct instruction for GER. Diluting formula can reduce the nutritional value and increase the volume of the feedings, which can worsen GER symptoms and cause dehydration and malnutrition.
Choice B reason: Place the newborn in a side-lying position if vomiting is not a correct instruction for GER. This position can increase the risk of aspiration, which is the inhalation of vomit into the lungs. Aspiration can cause pneumonia, respiratory distress, and death.
Choice C reason: Position the newborn at a 20-degree angle after feeding is a correct instruction for GER. This position can help prevent reflux by using gravity to keep the stomach contents down. The newborn should be kept upright for at least 30 minutes after each feeding.
Choice D reason: Provide a small feeding just before bedtime is not a correct instruction for GER. This can increase the likelihood of reflux during sleep, as the stomach will be full and prone to regurgitation. The last feeding should be given at least 2 to 3 hours before bedtime.
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