A nurse is caring for a client who has acute dehydration and is receiving IV fluids.
Which of the following laboratory values indicates to the nurse that the current treatment regimen is effective?
Sodium 165 mEq/L
Hematocrit 62.5
Urine specific gravity 1.020
D. Potassium 3.2 mEq/L
D. Potassium 3.2 mEq/L
The Correct Answer is C
Choice A rationale
A sodium level of 165 mEq/L is higher than the normal range and could indicate that the body is still dehydrated.
Choice B rationale
A hematocrit of 62.5 is higher than the normal range and could suggest that the body is still dehydrated.
Choice C rationale
A urine specific gravity of 1.020 is within the normal range and suggests that the body is rehydrating effectively.
Choice D rationale
A potassium level of 3.2 mEq/L is lower than the normal range and could suggest that the body’s electrolyte balance has not yet been restored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.
Choice B rationale
Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.
Choice C rationale
Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.
Choice D rationale
Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.
Correct Answer is D
Explanation
Choice A rationale
Aspiration is not a common complication of TPN. TPN is administered intravenously, bypassing the gastrointestinal tract, which reduces the risk of aspiration. Choice B rationale
Polyuria, or excessive urination, is not typically a direct complication of TPN. However, the fluid balance of patients on TPN should be monitored, as both overhydration and dehydration can lead to urinary changes.
Choice C rationale
Stomatitis, or inflammation of the mouth and lips, is not a common complication of TPN. Since TPN bypasses the gastrointestinal tract, it does not typically cause oral complications.
Choice D rationale
Abdominal distention can occur as a complication of TPN. This is because TPN can cause an imbalance in the gut flora, leading to gas production and bloating. Additionally, if a patient on TPN has an underlying condition that affects gut motility, they may experience abdominal distention.
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