A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

BUN 18 mg/dL

Serum creatinine 1.0 mg/dL

Urine output 12 mL/hr

Urine specific gravity 1.020

Answer and Explanation

The Correct Answer is C

A. BUN 18 mg/dL is incorrect. A BUN (blood urea nitrogen) level of 18 mg/dL is within the normal range (typically 7–20 mg/dL) and does not indicate immediate concern in this context. An elevated BUN could indicate dehydration, but this level is not significantly elevated.

B. Serum creatinine 1.0 mg/dL is incorrect. Serum creatinine levels are also within normal limits for most adults, which is around 0.6–1.2 mg/dL, and this finding does not indicate a problem.

C. Urine output 12 mL/hr is correct. A urine output of 12 mL/hr is low and indicates oliguria, which is a concern in the context of dehydration. The normal urine output for an adult is at least 30 mL/hr. A decrease in urine output suggests that the kidneys are not receiving adequate blood flow, which could indicate severe dehydration and requires immediate attention from the provider.

D. Urine specific gravity 1.020 is incorrect. Urine specific gravity of 1.020 is within the normal range (typically 1.005–1.030) and indicates that the kidneys are concentrating urine appropriately, which is not a concerning finding in this case.

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Correct Answer is D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

A. A nurse discusses a client's postoperative complications during shift report. B. A facility risk manager includes information from a client's medical record in a when report. C. A nurse tells the chaplain that a client has a new diagnosis of cancer. D. A social worker reads a client's chart as a follow-up to a requested consultation.

Correct Answer is C

Explanation

A. "A nurse discusses a client's postoperative complications during shift report.": This is not a breach of confidentiality if the information is shared within the context of a healthcare team for the purpose of providing care. Confidentiality is maintained as long as the information is shared appropriately.

B. "A facility risk manager includes information from a client's medical record in a when report.": This is also not necessarily a breach of confidentiality if the report is used for quality improvement, risk management, or other institutional purposes where confidentiality protocols are followed.

C. "A nurse tells the chaplain that a client has a new diagnosis of cancer.": This is a breach of confidentiality. Information should only be shared with others involved in the patient's care or if the patient has given explicit consent. Discussing a client's diagnosis with a chaplain or anyone not directly involved in the care plan is an unauthorized disclosure.

D. "A social worker reads a client's chart as a follow-up to a requested consultation.": This is not a breach of confidentiality if the social worker is following established protocols for patient care and is authorized to access the client's medical records for consultation purposes.

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A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

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