An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Protein.

Hemoglobin.

White blood cell count

Sodium.

Answer and Explanation

The Correct Answer is D

A.   While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B.   Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C.   The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D.   Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.

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Correct Answer is D

Explanation

A. Dehiscence refers to the separation or opening of a wound’s edges, usually occurring after surgical closure. This can be due to several factors including infection, mechanical stress, or inadequate wound healing. If the incision shows signs of separation or gaping, this term would be appropriate. However, without a visual description or image, it’s unclear if the incision exhibits these characteristics.
B. This term implies that the incision is progressing towards recovery with no significant issues such as infection or dehiscence. This documentation is used when the wound appears clean, dry, and without signs of complications.
C. An infected incision typically shows signs such as increased redness, warmth, swelling, purulent drainage, or an unpleasant odor. If the incision displays these signs, it would be appropriate to document it as infected.
D. This term indicates that the edges of the incision are closely aligned, which is often used to describe an incision that is healing by primary intention. The edges are expected to come together neatly without separation.

A. Encourage the spouse to share their feelings. B. Offer reassurance that the spouse is not alone. C. Explain that alternative treatment options may be helpful. D. Remind the spouse that the client may still live a long time.

Correct Answer is A

Explanation

A. Encouraging the spouse to share their feelings is the most appropriate initial action. It provides an opportunity for the spouse to express their emotions and begin processing their grief. This approach validates the spouse’s feelings, offers emotional support, and establishes a supportive environment where the spouse can feel heard and understood.
B. Offering reassurance that the spouse is not alone can be comforting, but it may not fully address the immediate emotional needs of the spouse. It is important to first allow the spouse to express their feelings and then provide reassurance as part of the ongoing support.
C. Discussing alternative treatment options may be premature and could be perceived as dismissive of the spouse’s immediate emotional response. At this moment, the spouse is focused on the emotional impact of the terminal diagnosis rather than treatment options.
D. While offering hope can be part of supportive care, this approach might unintentionally minimize the spouse’s current feelings of loss and grief. It can also come across as dismissive of the immediate emotional impact of the diagnosis.

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An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

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Naxlex Comprehensive Predictor Exams

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Correct Answer is D

Explanation

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is A

Explanation

A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?