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 D
Explanation
A: Sedation is not typically required for PICC line insertion; local anesthesia is usually sufficient.
B: An MRI is not the standard method to verify PICC line placement; an x-ray is typically used.
C: Using gauze to secure an arm board can restrict circulation and is not recommended for securing a PICC line.
D: Measuring the arm circumference daily is important to monitor for complications such as swelling or phlebitis at the insertion site.
Correct Answer is C
Explanation
A. Having social support from friends is a protective factor against child abuse.
B. Seeking support from other parents indicates a healthy coping mechanism and reduces the risk of child abuse.
C. This statement suggests unrealistic expectations about the baby's development and behavior, which could lead to frustration and increased risk of child abuse. Unrealistic expectations are a risk factor for abusive behavior towards children.
D. This statement reflects attentiveness and responsiveness to the baby's needs, which reduces the risk of child abuse.
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