A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

RBC count

WBC count

Potassium

BUN

Answer and Explanation

The Correct Answer is B

A.   An elevation in the red blood cell (RBC) count is not a specific indication of infection. It primarily reflects oxygen-carrying capacity.
B.   An elevation in the white blood cell (WBC) count is an indication of infection. When the body is fighting an infection, the number of white blood cells increases as part of the immune response.
C.   Potassium is an electrolyte and is not a specific marker for infection. Abnormal potassium levels may indicate a variety of conditions, but they do not directly indicate infection.
D.   Blood urea nitrogen (BUN) is a marker of kidney function and is not a specific indicator of infection. Elevated BUN levels can be seen in various kidney and non-kidney-related conditions.

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Correct Answer is C

Explanation

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

A. inguinal canal B. knee C. lower third of the tibia D. dorsal aspect of the foot

Correct Answer is C

Explanation

A. Inguinal canal is not the correct location for assessing the posterior tibial pulse. This area is associated with the femoral pulse.
B. The knee is not the correct location for assessing the posterior tibial pulse. This area is not directly related to the posterior tibial pulse.
C. The lower third of the tibia, anterior aspect is the correct location for palpating the posterior tibial pulse. This pulse can be found on the inside of the ankle, slightly below and behind the medial malleolus.
D. Dorsal aspect of the foot is where the dorsalis pedis pulse is located, not the posterior tibial pulse.

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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is C

Explanation

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