A nurse is reviewing the laboratory results for four clients. Which of the following results is the priority for the nurse to report to the provider?
WBC 11,000/mm² in a client who is starting treatment for a methicillin-resistant staphylococcus aureus (MRSA) infection.
Serum pH 7.25 in a client who has type 1 diabetes mellitus.
Hematocrit 26% in a client who has sickle cell disease.
Urine specific gravity 1.032 in a client who is diagnosed with dehydration.
The Correct Answer is B
Choice A rationale:
An elevated WBC count (11,000/mm²) in a client starting treatment for MRSA infection may indicate an inflammatory response, but it is expected in this scenario, and the priority is not as high as other critical lab values.
Choice B rationale:
A serum pH of 7.25 indicates acidosis, which is a potentially life-threatening condition. In type 1 diabetes mellitus, diabetic ketoacidosis (DKA) is a common complication that can lead to metabolic acidosis. This lab result is a priority as it requires immediate attention.
Choice C rationale:
Hematocrit of 26% in a client with sickle cell disease might be low, but it is not the priority over the critically abnormal lab value of serum pH in option B.
Choice D rationale:
A urine specific gravity of 1.032 in a client diagnosed with dehydration is elevated, indicating concentrated urine due to dehydration. While dehydration is concerning, it is not as high-priority as the potentially life-threatening acidosis in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.
Choice B rationale:
A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.
Choice C rationale:
The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.
Choice D rationale:
Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.
Correct Answer is A
Explanation
the correct answer is Choice A.
Choice A rationale: Basal cell carcinoma (BCC) is a type of skin cancer that develops in basal cells, a type of cell within the skin that produces new skin cells1.One of the common symptoms of BCC is a pearly white, skin-colored or pink bump1.This can also appear as a shiny or pearly nodule with a smooth surface2.Therefore, a pearly, waxy nodule is a characteristic lesion of basal cell carcinoma
Choice B rationale: An irregular border on a variegated-colored lesion is more commonly associated with melanoma, another type of skin cancer, rather than basal cell carcinoma1.While BCC can have a variety of appearances, an irregular border on a variegated-colored lesion is not typically characteristic of BCC
Choice C rationale: A firm, nodular, crusty, or ulcerated lesion can be a sign of several types of skin conditions, including squamous cell carcinoma, another type of skin cancer1.While BCC can sometimes appear as a firm nodule1, the description of a crusty or ulcerated lesion is not as characteristic of BCC as a pearly, waxy nodule
Choice D rationale: A weeping vesicle is not typically associated with basal cell carcinoma1.BCC lesions are more likely to appear as a shiny bump or nodule, or a flat, scaly patch1.A weeping vesicle could be indicative of a different skin condition
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