Exhibits
A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Prealbumin
Temperature
Urine specific gravity
Bowel sounds
The Correct Answer is C
A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a
borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: While social workers can assist with many aspects of care, they may not always be able to provide legal representation or assistance.
B: While legal representation can be helpful, advance directives can be valid and legally binding documents even without it.
C: Verbal agreements are generally not sufficient for advance directives; written documentation is typically required.
D: While medical care can be initiated regardless of advance directives, it's important to inform the client that they can create directives without immediate legal assistance.
Correct Answer is D
Explanation
A. The infants’s head should not be covered while receiving phototherapy, as the skin needs to be exposed to the therapy. However, it is essential to ensure that the infant's eyes are protected from the light.
B. Applying lotion may interfere with the effectiveness of phototherapy by blocking the light’s effects and is unnecessary for managing jaundice in newborns.
C. Giving glucose water is unnecessary and may interfere with the infant's hydration and nutritional needs during phototherapy.
D. Ensuring that the newborn wears a diaper to prevent soiling of the phototherapy equipment and to allow for the monitoring of urinary output, which is an important indicator of the newborn's health during treatment.
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