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 A

Explanation

The correct answer is: a. Place a black tag on the client’s upper body and attempt to help the next client in need.

Choice A: Place a black tag on the client’s upper body and attempt to help the next client in need.

In mass casualty incidents, the START (Simple Triage and Rapid Treatment) triage system is often used. According to this system, if a patient is apneic (not breathing) and does not resume breathing after repositioning the airway, they are considered deceased or non-salvageable and should be tagged with a black tag. This allows the nurse to focus on other victims who have a higher chance of survival.

Choice B: Start CPR

While starting CPR might seem appropriate in a normal setting, during a mass casualty incident, resources and time are limited. The priority is to save as many lives as possible. Performing CPR on an apneic patient with a weak pulse would take significant time and resources that could be used to help other victims with a higher chance of survival.

Choice C: Place a red tag on the client’s upper body and obtain immediate help from other personnel.

A red tag is used for patients who need immediate care and have a high chance of survival if treated promptly. Since the client remains apneic even after repositioning the airway, they do not meet the criteria for a red tag.

Choice D: Reposition the client’s upper airway a second time before assessing his respirations.

Repositioning the airway a second time is not recommended in the START triage system. If the patient does not resume breathing after the initial repositioning, they are considered non-salvageable.

A. Fatigue B. Dyspnea C. Oliguria D. Pitting edema

Correct Answer is A

Explanation

Choice A: Fatigue is a manifestation that the nurse should identify as indicating the client is hypokalemic. Hypokalemia is a condition in which the blood potassium level is lower than normal, usually due to excessive loss of potassium through urine, sweat, or vomiting. Potassium is an electrolyte that is essential for nerve and muscle function, especially for the heart. Hypokalemia can cause muscle weakness, cramps, and fatigue, as well as cardiac arrhythmias and dysrhythmias.

Choice B: Dyspnea is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Dyspnea is a sensation of difficulty breathing or shortness of breath. Dyspnea can be caused by various conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, or pulmonary edema. Dyspnea is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid accumulation in the lungs and impair gas exchange.

Choice C: Oliguria is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. Oliguria can be caused by various conditions, such as dehydration, kidney failure, urinary tract obstruction, or shock. Oliguria is not directly related to hypokalemia, but it can be a sign of kidney damage or impairment, which can aﬀect electrolyte balance and ﬂuid volume.

Choice D: Pitting edema is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. Pitting edema can be caused by various conditions, such as venous insufficiency, lymphedema, liver cirrhosis, or malnutrition. Pitting edema is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid retention and overload in the body.

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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

A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Correct Answer is A

Explanation

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