A nurse is caring for a male client who reports nausea and vomiting and is receiving IV ﬂuid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate?

Continue routine care because the results are within the expected reference range.

Evaluate urine for amount and for specific gravity.

Collect a urine specimen for culture and sensitivity.

Decrease the IV ﬂuid infusion rate and limit oral ﬂuid intake.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because the results are not within the expected reference range. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion.

Choice B Reason: This is correct because evaluating urine for amount and for specific gravity can help assess the client's hydration status and renal function. These actions can help assess the client's hydration status and renal function, which may be aﬀected by nausea and vomiting. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion. The normal ranges for BUN are 7 to 20 mg/dL, for creatinine are

0.6 to 1.2 mg/dL, and for hematocrit are 38% to 50% for males. The nurse should monitor the urine output and specific gravity, which reﬂect the concentration and volume of urine. The normal range for urine output is 30 to 60 mL/hour, and for specific gravity is 1.005 to 1.030.

Choice C Reason: This is incorrect because collecting a urine specimen for culture and sensitivity is not indicated for this client. This action is used to diagnose urinary tract infections, which are not suggested by the client's symptoms or results.

Choice D Reason: This is incorrect because decreasing the IV ﬂuid infusion rate and limiting oral ﬂuid intake can worsen the client's dehydration and renal perfusion. The nurse should maintain adequate ﬂuid intake and balance to prevent further complications.

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Correct Answer is B

Explanation

Choice A: Provide a brightly lit environment is not an intervention that the nurse should take. A brightly lit environment can stimulate the brain and increase intracranial pressure. The nurse should provide a quiet and dimly lit environment to reduce sensory stimuli and promote rest.

Choice B: Elevate the head of the bed is an intervention that the nurse should take. Elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage from the brain and decreasing cerebral blood volume. The nurse should avoid ﬂexing or extending the neck, which can impede blood ﬂow and increase intracranial pressure.

Choice C: Encourage a minimum intake of 2000 mL (67.6 oz) of clear ﬂuids per day is not an intervention that the nurse should take. A high ﬂuid intake can increase intracranial pressure by increasing blood volume and cerebral edema. The nurse should monitor ﬂuid balance and restrict ﬂuid intake as prescribed to maintain normal osmolality and prevent ﬂuid overload.

Choice D: Teach controlled coughing and deep breathing is not an intervention that the nurse should take. Coughing and deep breathing can increase intrathoracic pressure, which can increase intracranial pressure by reducing venous return from the brain. The nurse should avoid activities that can increase intrathoracic pressure, such as straining, sneezing, or blowing the nose. The nurse should also administer oxygen as prescribed to maintain adequate oxygenation and perfusion of the brain.

A. Clean the wound. B. Apply a tourniquet just below the elbow. C. Apply direct pressure over the wound. D. Elevate the limb and apply ice.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because cleaning the wound is not a priority when the client is bleeding profusely. Cleaning the wound can also dislodge any clots that have formed and increase bleeding.

Choice B Reason: This is incorrect because applying a tourniquet is a last resort when direct pressure fails to stop bleeding. A tourniquet can cause tissue damage, nerve injury, and infection if applied incorrectly or for too long.

Choice C Reason: This is correct because applying direct pressure over the wound is the first and most eﬀective action to stop bleeding from a wound. This is the first and most eﬀective action to stop bleeding from a wound. Direct pressure compresses the blood vessels and prevents further blood loss. The nurse should use a clean cloth or dressing to cover the wound and apply firm pressure with both hands.

Choice D Reason: This is incorrect because elevating the limb and applying ice are not eﬀective actions to stop bleeding from a wound. Elevating the limb can reduce blood ﬂow to the injured area, but it does not compress the blood vessels or prevent blood loss. Applying ice can cause vasoconstriction, but it can also damage the skin and tissues if applied for too long.

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A nurse is caring for a male client who reports nausea and vomiting and is receiving IV ﬂuid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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