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 ["A","D"]
Explanation
Choice A rationale:
Prolonged sun exposure is a risk factor for osteoporosis because it can lead to vitamin D deficiency. Vitamin D is essential for calcium absorption, and low levels of vitamin D can contribute to reduced bone density and increased risk of fractures.
Choice B rationale:
Reduced intake of vitamin E is not a well-established risk factor for osteoporosis. Vitamin E is an antioxidant and plays a role in various bodily processes, but its association with osteoporosis is not supported by strong evidence.
Choice C rationale:
Drinking one glass of wine per day is not a risk factor for osteoporosis. In fact, moderate alcohol consumption has been suggested to have a protective effect on bone density in some studies.
Choice D rationale:
Exposure to second-hand tobacco smoke is a risk factor for osteoporosis. Smoking and exposure to tobacco smoke have been linked to decreased bone density and increased risk of fractures, making this an important point to include in the teaching.
Correct Answer is A
Explanation
Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.
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