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. Coarctation of the aorta typically results in hypertension in the upper extremities due to increased pressure proximal to the coarctation.
B. Weak or absent femoral pulses are characteristic findings in coarctation of the aorta due to reduced blood flow to the lower extremities beyond the coarctation. This finding indicates peripheral vascular compromise in the lower limbs.
C. Frequent nosebleeds are not typically associated with coarctation of the aorta.
D. Coarctation of the aorta does not directly affect intracranial pressure.
Correct Answer is B
Explanation
A. Providing a cooling blanket may help reduce fever associated with a thyroid storm but is not the priority over monitoring the cardiac rhythm.
B. In a thyroid storm, the client is at risk for severe cardiovascular complications, including tachycardia, arrhythmias, and heart failure. Therefore, the nurse's priority action is to monitor the client's cardiac rhythm continuously to detect any abnormalities promptly and intervene as needed.
C. Administering 0.9% sodium chloride IV may be necessary to maintain fluid balance, but it's not the priority over cardiac monitoring.
D. Obtaining the client's blood glucose may be relevant but is not the priority in the acute management of a thyroid storm.
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