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. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.

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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