A nurse is caring for a patient who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the patient is effectively responding to treatment?

Urine specific gravity of 1.020

Serum sodium of 165 mEq/L

Hematocrit of 48%

Blood urea nitrogen (BUN) of 12 mg/dL

Answer and Explanation

The Correct Answer is A

Choice A reason: Urine specific gravity measures the kidney's ability to concentrate urine. A normal range is typically 1.005–1.030. A value of 1.020 indicates adequate hydration and suggests that the patient is responding well to IV fluid therapy.

Choice B reason: Serum sodium levels reflect electrolyte balance. The normal range is 135–145 mEq/L. A level of 165 mEq/L is significantly elevated, indicating hypernatremia, which could be a sign of inadequate hydration and not a positive response to treatment.

Choice C reason: Hematocrit represents the proportion of blood volume occupied by red blood cells. Normal ranges are 38.3–48.6% for men and 35.5–44.9% for women. A hematocrit of 48% is at the upper limit of normal and does not specifically indicate the effectiveness of dehydration treatment.

Choice D reason: Blood urea nitrogen (BUN) levels can indicate renal function and hydration status. The normal range is 7–20 mg/dL. A BUN of 12 mg/dL is within the normal range and does not specifically reflect the patient's response to IV fluids for dehydration.

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Correct Answer is C

Explanation

The correct answer is: c. Prepare the client for intubation.

Choice A: Prepare to administer a vasopressor

Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.

Choice B: Administer an anticholinesterase medication

Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.

Choice C: Prepare the client for intubation

Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.

Choice D: Instruct the client to perform pursed lip breathing

Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.

A. The test measures the hormone that attaches to a protein in your blood. B. The test measures the hormone that feeds the thyroid gland. C. The test measures the hormone that indicates the metabolic rate. D. The test measures the hormone that controls energy levels.

Correct Answer is C

Explanation

Choice A reason: The statement is incorrect because TSH does not attach to a protein in the blood; it stimulates the thyroid gland to produce thyroid hormones.

Choice B reason: This choice is partially correct. TSH does stimulate the thyroid gland, but the main purpose of the test is not to measure the 'feeding' of the gland but to assess its function and how well it's producing thyroid hormones.

Choice C reason: This is the correct statement. TSH levels are measured to determine the thyroid gland's activity, which directly influences the metabolic rate. The normal range for TSH levels in adults is typically 0.4 to 4.0 milliunits per liter (mU/L). However, these values can vary slightly based on the laboratory and the age of the individual.

Choice D reason: While TSH does influence energy levels by regulating thyroid hormone production, this choice does not directly explain the purpose of measuring TSH levels.

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A nurse is caring for a patient who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the patient is effectively responding to treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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