A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect?

WBC count 15,000/mm3

Sodium 130 mg/dL

BUN 8 mg/dL

Hematocrit 35%

Answer and Explanation

The Correct Answer is A

A high WBC count (leukocytosis) indicates an inflammatory response to an infection, such as pneumonia. The nurse should expect to see this value in a client who has pneumonia and monitor the client for signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). The other values are within normal or expected ranges for a client who has pneumonia.

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Correct Answer is D

Explanation

The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.

A. Weigh the client. B. Check for contraindications. C. Administer the tPA. D. Transfer the client to the CCU.

Correct Answer is B,A,C,D

Explanation

The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, thenurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.

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A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is B,A,C,D

Explanation

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