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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because magnesium is not a medication for symptomatic bradycardia. Magnesium is a mineral that regulates muscle and nerve function, blood pressure, and blood sugar levels. Magnesium can be used to treat conditions such as torsades de pointes, eclampsia, or hypomagnesemia.
Choice B Reason: This is incorrect because sodium bicarbonate is not a medication for symptomatic bradycardia. Sodium bicarbonate is a substance that neutralizes acids and bases and regulates the pH of the blood. Sodium bicarbonate can be used to treat conditions such as metabolic acidosis, cardiac arrest, or overdose of certain drugs.
Choice C Reason: This is incorrect because epinephrine is not a medication for symptomatic bradycardia. Epinephrine is a hormone that activates the sympathetic nervous system and increases the heart rate, blood pressure, and blood flow to the muscles and brain. Epinephrine can be used to treat conditions such as anaphylaxis, cardiac arrest, or severe asthma.
Choice D Reason: This is correct because atropine is a medication for symptomatic bradycardia. Atropine blocks the action of the parasympathetic nervous system and increases the heart rate and conduction. Atropine is a medication that blocks the action of the parasympathetic nervous system and increases the heart rate and conduction.
Symptomatic bradycardia is a condition where the heart rate is slower than normal and causes symptoms such as dizziness, fatigue, chest pain, or fainting. Atropine can be used to treat symptomatic bradycardia by stimulating the sinoatrial node and the atrioventricular node, which are the natural pacemakers of the heart.
Correct Answer is A
Explanation
Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deflation.
Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.
Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.
Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous fluids and nutrition as prescribed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today