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 A

Explanation

A. Clients receiving immune suppressant therapy, such as those undergoing treatment for cancer, are at a significantly increased risk for healthcare-associated infections. Immune suppressants weaken the body's ability to mount an effective immune response, making individuals more susceptible to infections.
B. Hyperemia, or increased blood flow to a particular area, can be a sign of an acute local infection. While it indicates the presence of infection, the hyperemia itself does not increase the risk of developing a new or additional healthcare-associated infection.
C. Weight loss, especially if associated with dietary changes, may affect overall health and nutritional status, potentially impairing wound healing and immune function. However, it is not as directly linked to an increased risk of HAIs as immune suppression or invasive procedures.
D. Receiving vaccinations generally aims to enhance immunity and protect against specific infections. Immunizations can help prevent infections but do not increase the risk of healthcare-associated infections. This action is preventive rather than a risk factor for HAIs.

A. Notify the charge nurse of the problem. B. Notify the healthcare provider of the situation. C. Discard the urine and start another 24-hour period. D. Add another hour to the urine collection period.

Correct Answer is C

Explanation

A. While it’s important to inform the charge nurse of any issues with the collection process, this action alone does not address the core problem of the collection being compromised. The charge nurse may offer guidance or assist in deciding the next steps, but the primary focus should be on correcting the collection process to ensure accurate results.
B. Notifying the healthcare provider can be important, especially if the results of the 24-hour urine collection are critical to the client’s diagnosis or treatment plan. However, it is usually more efficient to first address the issue of the collection itself and then inform the healthcare provider about the results of these corrective actions.
C. This is the most appropriate action when a mistake occurs in the collection process, such as flushing a voided sample. The integrity of the collection is compromised, and starting a new 24-hour collection period ensures that all samples are accounted for and that the results will be accurate.
D. Adding extra time to the urine collection period does not compensate for the missed sample. The accuracy of the collection depends on having all urine samples from the full 24-hour period.

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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

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

Correct Answer is A

Explanation

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

Correct Answer is C

Explanation

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