The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

White blood cells

Platelets

Red blood cells

Hematocrit

Answer and Explanation

The Correct Answer is A

A. White blood cells (WBCs): The nurse should monitor the client's white blood cell count to assess their ability to withstand exposure to pathogens. WBCs are integral to the body's immune response, as they play a crucial role in defending against infections. An elevated or decreased WBC count can indicate an underlying infection or immune dysfunction, helping the nurse identify potential risks to the client's health. Regular monitoring of WBC levels allows for timely intervention and assessment of the client's immune status.

B. Platelets: Platelets are primarily responsible for blood clotting and are not directly involved in the body's immune response to pathogens. While they are important for hemostasis and preventing excessive bleeding, monitoring platelet count is not directly indicative of a client's ability to withstand exposure to pathogens.

C. Red blood cells: Red blood cells (RBCs) are responsible for transporting oxygen throughout the body and are not directly involved in the immune response to pathogens. Monitoring red blood cell count, hemoglobin, and hematocrit levels is important for assessing oxygen-carrying capacity and detecting conditions such as anemia, but it does not provide specific information about the client's ability to combat infections.

D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is used to assess blood volume and oxygen-carrying capacity. While changes in hematocrit levels may indirectly indicate certain health conditions, such as dehydration or polycythemia, it does not directly reflect the client's immune status or ability to withstand exposure to pathogens.

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Correct Answer is B

Explanation

A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments. Cloudy, amber urine with an unpleasant odor is not indicative of functional incontinence.

B. Urinary tract infection (UTI): Cloudy, amber urine with an unpleasant odor is a common symptom of a UTI. UTIs often cause changes in urine color, odor, and clarity due to the presence of bacteria and inflammatory cells in the urine.

C. Ketone bodies in the urine: Ketones in the urine can occur in conditions such as uncontrolled diabetes or during periods of fasting. However, cloudy, amber urine with an unpleasant odor is more indicative of a UTI rather than the presence of ketones.

D. Nocturia: Nocturia refers to waking up during the night to urinate. While it may be associated with certain urinary conditions, it does not directly correlate with the appearance and odor of the urine.

A. Daily weights, vital signs and fluid intake and output B. Monitoring temperature, fluid intake and output and administering IV fluids C. Auscultation of lung sounds. Monitoring urine color and placing an indwelling urinary catheter in the client D. Daily weights, diuretics and waist measurement

Correct Answer is A

Explanation

A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.

B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.

C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.

D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.

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The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

Correct Answer is B

Explanation

The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?

Correct Answer is A

Explanation

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