A nurse is reviewing the laboratory results of a female client who has liver dysfunction a receiving a continuous tube feeding. Which of the findings should the nurse identify as a protein deficiency?
Albumin 3.1 g/dL (3.5 to 5.0 g/dL)
Transferrin 400 mg/dL (250 to 380 mg/dL)
Uric acid 2.3 mg/dL (2.7 to 7.3 mg/dL)
Total iron-binding capacity 488 mcg/dL (250 to 460 mcg/dL)
The Correct Answer is A
A. Albumin 3.1 g/dL (3.5 to 5.0 g/dL)
Albumin is a protein produced by the liver, and its levels are commonly used as an indicator of nutritional status, particularly protein status. In clients with liver dysfunction and receiving continuous tube feeding, a low albumin level indicates protein deficiency. Albumin plays a crucial role in maintaining oncotic pressure in the blood vessels, and decreased levels can lead to fluid shifts and edema, among other complications.
B. Transferrin 400 mg/dL (250 to 380 mg/dL):
Transferrin is a protein involved in iron transport. While high transferrin levels may indicate iron deficiency, they do not directly reflect protein deficiency.
C. Uric acid 2.3 mg/dL (2.7 to 7.3 mg/dL):
Uric acid is a waste product of metabolism. Low uric acid levels are not indicative of protein deficiency; instead, they may be seen in conditions such as liver dysfunction or decreased production of uric acid.
D. Total iron-binding capacity 488 mcg/dL (250 to 460 mcg/dL):
Total iron-binding capacity measures the amount of iron that can be bound by transferrin. Elevated total iron-binding capacity may indicate iron deficiency, but it does not directly reflect protein deficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Level of orientation:
The level of orientation refers to the client's cognitive status and ability to understand their surroundings. While important for overall assessment and care planning, it is not typically included in anthropometric assessment, which focuses specifically on physical measurements and characteristics of the body.
B. Respiratory rate:
Respiratory rate is a vital sign that reflects the client's respiratory status and is important for assessing oxygenation and ventilation. However, it is not part of anthropometric assessment, which primarily focuses on physical measurements related to body size, shape, and composition.
C. Weight
Anthropometric assessment involves the measurement of various body dimensions, such as height, weight, and body composition. Weight is a crucial component of anthropometric assessment as it provides information about the client's nutritional status, growth patterns, and overall health. Monitoring changes in weight over time can help identify trends and assess the effectiveness of interventions aimed at improving nutritional status or managing health conditions.
D. Current pain level:
Pain level is important for assessing the client's comfort and managing pain effectively, but it is not included in anthropometric assessment. Anthropometric assessment focuses on objective measurements of body dimensions and characteristics rather than subjective experiences such as pain.
Correct Answer is C
Explanation
A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.
B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.
C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.
D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.
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