A nurse is assisting with the care of a client.
The laboratory results indicate abnormalities.
Which of the following actions should the nurse take?
Place the client on NPO status.
Administer a prescribed medication.
Monitor the client for signs of dehydration.
Encourage oral fluid intake.
The Correct Answer is C
Choice A rationale
Placing the client on NPO status is required for some specific conditions, such as prior to surgery or when there is risk of aspiration. However, this should not be the first action unless the abnormalities clearly indicate such a need. Monitoring the client’s overall condition should take precedence.
Choice B rationale
Administering a prescribed medication could be helpful depending on the specific abnormality. However, this action depends on the nature of the abnormality and medical orders. It is not the initial step unless a clear order has been provided for a specific issue.
Choice C rationale
Monitoring for signs of dehydration is critical, as dehydration can exacerbate the abnormalities and negatively impact homeostasis. Ensuring the client’s condition does not worsen is a priority, as hydration status often affects laboratory values and overall well-being.
Choice D rationale
Encouraging oral fluid intake is important to prevent or correct dehydration, particularly if lab abnormalities suggest volume depletion. However, it is not the first step. Initial monitoring is required to guide further interventions like fluid intake recommendations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.7"]
Explanation
Step 1 is (150 lb × 1 kg ÷ 2.2 lb) × 250 units. This calculates the total units required. The answer is 17045.45 units.
Step 2 is 17045.45 units ÷ 10,000 units/mL = 1.7 mL.
The final calculated answer is 1.7 mL.
Correct Answer is A
Explanation
Choice A rationale
Exophthalmos is characterized by abnormal protrusion or bulging of the eyes due to retro-orbital tissue swelling and inflammation associated with Graves’ disease. This condition is a hallmark symptom of Graves’ ophthalmopathy.
Choice B rationale
Sunken eyes are not indicative of exophthalmos and are typically associated with dehydration or aging, rather than retro-orbital tissue changes as seen in Graves’ disease.
Choice C rationale
Eyelid swelling might occur in various conditions, such as allergies or infections, but it does not specifically point to exophthalmos or Graves’ disease-related complications.
Choice D rationale
Redness and watering of the eyes are non-specific symptoms that could occur in conjunctivitis or dry eye syndrome but do not define exophthalmos uniquely.
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