A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained.

Reference Range:

Potassium (K+): 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

Sodium (Na+): 136 to 145 mEq/L (136 to 145 mmol/L)

Which laboratory results should the nurse expect?

Serum potassium: 3.5 mEq/L (3.5 mmol/L), serum sodium: 142 mEq/L (142 mmol/L)

Serum potassium: 4.5 mEq/L (4.5 mmol/L), serum sodium: 140 mEq/L (140 mmol/L)

Serum potassium: 5.0 mEq/L (5.0 mmol/L), serum sodium: 138 mEq/L (138 mmol/L)

Serum potassium: 3.0 mEq/L (3.0 mmol/L), serum sodium: 149 mEq/L (149 mmol/L)

Answer and Explanation

The Correct Answer is A

Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.

Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.

Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.

Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.

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Correct Answer is C

Explanation

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

A. C-reactive protein level B. Serum potassium and sodium levels C. Neutrophil count D. Platelet count

Correct Answer is A

Explanation

Choice A reason: An increased boundary of the wound suggests possible infection or inflammation. C-reactive protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation. A CRP test can help assess the severity of inflammation or infection. The normal range for CRP is generally below 10 mg/L.

Choice B reason: While serum potassium and sodium levels are important electrolytes to monitor, they are not directly related to wound assessment or infection. Normal ranges for potassium are 3.6 to 5.2 mmol/L, and for sodium, 135 to 145 mEq/L.

Choice C reason: Neutrophils are white blood cells that respond to infection. While an elevated neutrophil count can indicate infection, it is not as specific as CRP for inflammation. The normal range for neutrophils is 2,500 to 6,000 cells/mcL.

Choice D reason: Platelets are involved in clotting and would not necessarily change due to wound infection or inflammation. The normal platelet count range is 150,000 to 450,000 platelets/mcL.

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Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is A

Explanation

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?