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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement is incorrect because after instilling ointment, the client should close their eye gently and avoid blinking to allow the ointment to spread over the conjunctival sac.
B. When applying ophthalmic ointment, the client should pull down the lower eyelid to create a small pocket (conjunctival sac) and then apply a thin line of ointment along this pocket. This method helps the ointment distribute evenly over the affected area.
C. While this is a correct technique for cleaning around the eye, it is not directly related to the application of ophthalmic ointment.
D. This statement is unnecessary and may confuse the client. It's typically not required to use sterile gloves for applying ophthalmic ointment, and most ointments come with a sterile applicator or can be applied using clean hands if instructed to do so by a healthcare provider.
Correct Answer is B
Explanation
A. Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B. This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C. Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D. Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.
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