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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Choice A Reason:
Jugular venous distension is correct. Jugular venous distension is a common sign of fluid overload and increased central venous pressure, which occur during exacerbations of heart failure. It indicates impaired cardiac function and elevated systemic venous pressure.
Choice B Reason:
Peripheral edema is correct. Peripheral edema, particularly in the lower extremities, is a classic manifestation of fluid retention and congestion in heart failure exacerbations. It results from increased capillary hydrostatic pressure and impaired fluid reabsorption by the kidneys.
Choice C Reason:
Dyspnea is correct. Dyspnea, or shortness of breath, is a hallmark symptom of heart failure exacerbations. It occurs due to pulmonary congestion resulting from fluid accumulation in the lungs, impairing gas exchange and leading to difficulty breathing.
Choice D Reason:
Intercostal retraction is not typically associated with exacerbations of heart failure. Intercostal retractions indicate increased work of breathing and respiratory distress, which may occur in conditions such as severe respiratory infections or asthma exacerbations, but are not specific to heart failure exacerbations.
Choice E Reason:
Headaches are not typically associated with exacerbations of heart failure. Headaches can have various causes, including tension, migraines, or sinus congestion, but they are not commonly observed as a direct manifestation of heart failure exacerbations.

A. Fluid volume excess. B. Unbalanced nutrition, less than body needs. C. Unbalanced nutrition, greater than body needs. D. Fluid volume deficit.

Correct Answer is B

Explanation

Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.

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

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Naxlex Comprehensive Predictor Exams

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

Correct Answer is B

Explanation

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