A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Temperature 38.2° C (100.8° F)

Hematocrit 45%

Respiratory rate 12/min

Urine specific gravity 1.015

Answer and Explanation

The Correct Answer is A

A.   This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B.   Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C.   A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D.   Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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Correct Answer is A

Explanation

A. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.

A. Speaks in short phrases B. Increased sputum production C. Use of accessory muscles to breathe D. Pulse oximetry reading of 90%

Correct Answer is C

Explanation

A. Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B. Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C. This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D. A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.

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A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?

Correct Answer is A

Explanation

A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

Correct Answer is C

Explanation

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