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. Obtain the provider's signature within 8 hr. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record. D. Implement a recorded order message if the nurse can hear and understand it clearly. E. beat the order back to the provider.

Correct Answer is ["B","C","E"]

Explanation

A. Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B. Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C. Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D. Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E. Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.

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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

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