The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

White blood cell count (WBC).

Glucose.

Blood urea nitrogen (BUN).

Hematocrit.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
White blood cell count (WBC) is inappropriate. White blood cell count is typically monitored to assess for signs of infection or inflammation. While it's important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection. Therefore, monitoring WBC count may not be the most immediate response to the finding of melena.
Choice B Reason:
Glucose is inappropriate. Glucose monitoring is essential for patients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, melena is not directly related to glucose metabolism or regulation. Therefore, monitoring glucose levels would not be the most relevant response to the finding of melena.
Choice C Reason:
Blood urea nitrogen (BUN) is inappropriate. Blood urea nitrogen is often monitored to assess kidney function and hydration status. While severe bleeding can potentially lead to hypovolemia and prerenal azotemia (elevated BUN due to decreased renal perfusion), monitoring BUN would not be the immediate response to the finding of melena. Instead, assessing for signs of hypovolemia and monitoring other markers of blood loss, such as hematocrit, would be more appropriate.
Choice D Reason:
Hematocrit is appropriate. Melena refers to the passage of black, tarry stools containing blood that has been digested. It indicates upper gastrointestinal bleeding, typically from the stomach or upper small intestine. Monitoring the hematocrit level is important because significant bleeding, as indicated by melena, can lead to a decrease in the hematocrit level due to the loss of red blood cells and plasma volume. Monitoring the hematocrit helps assess the severity of the bleeding and guides treatment decisions, such as the need for blood transfusions. Therefore, the nurse should monitor the hematocrit level in response to the finding of melena.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

A. Review the client's serum electrolytes. B. Evaluate client's muscle strength and hand grips. C. Check distal phalanges capillary refill. D. Observe skin for erythema, edema, and warmth.

Correct Answer is B

Explanation

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is A

Explanation

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Correct Answer is B

Explanation

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical. Exhibits Nurse analyzes the findings. What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

An adult client exhibits an allergic reaction to an Insect bite. The nurse should observe the client's skin for which finding?

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

In assessing a client's level of consciousness, what should the nurse assess first?