A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate?
Continue routine care because the results are within the expected reference range.
Evaluate urine for amount and for specific gravity.
Collect a urine specimen for culture and sensitivity.
Decrease the IV fluid infusion rate and limit oral fluid intake.
The Correct Answer is B
Choice A Reason: This is incorrect because the results are not within the expected reference range. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion.
Choice B Reason: This is correct because evaluating urine for amount and for specific gravity can help assess the client's hydration status and renal function. These actions can help assess the client's hydration status and renal function, which may be affected by nausea and vomiting. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion. The normal ranges for BUN are 7 to 20 mg/dL, for creatinine are
0.6 to 1.2 mg/dL, and for hematocrit are 38% to 50% for males. The nurse should monitor the urine output and specific gravity, which reflect the concentration and volume of urine. The normal range for urine output is 30 to 60 mL/hour, and for specific gravity is 1.005 to 1.030.
Choice C Reason: This is incorrect because collecting a urine specimen for culture and sensitivity is not indicated for this client. This action is used to diagnose urinary tract infections, which are not suggested by the client's symptoms or results.
Choice D Reason: This is incorrect because decreasing the IV fluid infusion rate and limiting oral fluid intake can worsen the client's dehydration and renal perfusion. The nurse should maintain adequate fluid intake and balance to prevent further complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a) is incorrect because morphine sulfate is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that can relieve pain, anxiety, and dyspnea. Morphine sulfate can also reduce the preload and afterload of the heart, which can improve the cardiac output and oxygenation.
Choice b) is incorrect because laboratory testing of serum potassium is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that is important for the normal function of the cardiac cells and muscles. Serum potassium can be altered by various factors, such as renal function, acid-base balance, medications, or dietary intake. Serum potassium can affect the cardiac rhythm and contractility, which can influence the outcome of the client.
Choice c) is correct because 0.9% normal saline IV at 50 mL/hr continuous is a prescription that requires clarification for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that can maintain the fluid balance and blood pressure in the body. However, 0.9% normal saline can also cause fluid overload and worsen the heart failure symptoms, such as edema, crackles, and dyspnea. The nurse should clarify with the provider if this prescription is appropriate for the client's condition and if there are any parameters or limits for the fluid administration.
Choice d) is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that can increase the urine output and reduce the fluid volume and pressure in the body. Bumetanide can also decrease the preload and afterload of the heart, which can improve the cardiac output and oxygenation.
Correct Answer is B
Explanation
Choice a) is incorrect because vesicles on the skin are a sign of cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax is caused by direct contact with anthrax spores through a break in the skin. It causes a painless, black, necrotic lesion on the affected area.
Choice b) is correct because respiratory failure is a sign of inhalation anthrax, which is the most deadly form of anthrax. Inhalation anthrax is caused by breathing in anthrax spores that enter the lungs and spread to the bloodstream. It causes severe breathing problems, chest pain, shock, and death.
Choice c) is incorrect because sloughing of skin is a sign of necrotizing fasciitis, not inhalation anthrax. Necrotizing fasciitis is a rare bacterial infection that destroys the soft tissue under the skin. It causes severe pain, swelling, redness, blisters, and gangrene.
Choice d) is incorrect because flu-like symptoms are not specific to inhalation anthrax. Flu-like symptoms can be caused by many other conditions, such as influenza, common cold, or COVID-19. Flu-like symptoms include fever, cough, sore throat, headache, and muscle aches.
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