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).
Blood urea nitrogen (BUN).
Hematocrit.
Glucose.
The Correct Answer is C
Choice A rationale
White blood cell count (WBC) 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.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.
Choice B rationale
Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.
Choice C rationale
Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.
Choice D rationale
Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.
Correct Answer is D
Explanation
Choice A rationale
Paresthesia refers to abnormal sensations such as tingling or numbness, which is not indicated by the client’s ability to sense two points at specific distances.
Choice B rationale
A marginal decline in sensory function would be indicated by a significant increase in the distance required to sense two points, which is not the case here.
Choice C rationale
A rebound reaction to the needle points is not a recognized interpretation of the two-point discrimination test.
Choice D rationale
The client’s ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination.
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