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 A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

A. Dilute each medication with 10 mL of tap water. B. Pinch the tube prior to attaching the medication syringe. C. Reattach the suction directly after administering the medication. D. Mix the three medications together prior to administering.

Correct Answer is B

Explanation

A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.

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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

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