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 D
Explanation
Choice A rationale
A small amount of dark red wound drainage, such as 20 mL over 4 hours, is a typical postoperative finding in clients following bowel surgery. This observation indicates normal postoperative healing and does not require immediate intervention, making it a lower priority.
Choice B rationale
Pain at the incision site rated as 6 out of 10 is a moderate pain level that is expected in the postoperative period. While managing pain is important, this is not an urgent priority compared to other clinical findings that indicate systemic compromise or potential complications.
Choice C rationale
Dark yellow urine output totaling 60 mL over 4 hours reflects low urine output but does not meet the oliguria threshold of less than 30 mL per hour. This finding may require further assessment but is not immediately critical compared to symptoms of altered consciousness.
Choice D rationale
A client arousing easily but quickly falling back asleep indicates a potential alteration in consciousness, which can result from hypovolemia, hypoxia, or other complications. This finding is a priority for reporting as it may signify deteriorating neurological or hemodynamic status that requires immediate intervention. .
Correct Answer is B
Explanation
Choice A rationale
Cervical cancer screenings are recommended to begin at age 21, regardless of sexual history. Delaying until age 40 overlooks guidelines that target the detection of precancerous changes earlier in life, maximizing prevention efforts.
Choice B rationale
The combination of Pap and HPV tests every five years from ages 30 to 65 aligns with current recommendations. HPV is a critical etiological agent, and co-testing enhances sensitivity for detecting high-risk oncogenic strains or cellular abnormalities.
Choice C rationale
Immunization against HPV significantly reduces cervical cancer risk but does not eliminate it. Screening remains critical due to the vaccine's limited coverage of HPV types and possible pre-immunization exposure.
Choice D rationale
Lifetime screenings are not necessary unless there are risk factors like HIV or previous abnormal results. Guidelines recommend stopping screening after age 65 for women with adequate prior negative results.
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