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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect. Widening pulse pressure is not a sign of hypovolemic shock, but rather of increased intracranial pressure or aortic regurgitation. Hypovolemic shock causes narrowing pulse pressure due to decreased stroke volume and increased peripheral resistance.
Choice B Reason: This is correct. Increased heart rate is a sign of hypovolemic shock, as the body tries to compensate for the decreased blood volume and cardiac output by increasing the heart rate and contractility.
Choice C Reason: This is incorrect. Increased deep tendon reflexes are not a sign of hypovolemic shock, but rather of hyperreflexia or tetany. Hypovolemic shock causes decreased deep tendon reflexes due to reduced perfusion and oxygenation of the muscles and nerves.
Choice D Reason: This is incorrect. Pulse oximetry 96% is not a sign of hypovolemic shock, but rather of normal oxygen saturation. Hypovolemic shock causes decreased pulse oximetry due to hypoxia and impaired gas exchange.
Correct Answer is C
Explanation
Choice A: Check the tubing connections for leaks is not an action that the nurse should take. Leaks in the tubing connections can cause continuous or intermitent bubbling in the water seal chamber, not in the suction control chamber. The water seal chamber is the part of the closed chest drainage system that prevents air from entering the pleural space and allows air to escape from the chest tube. The nurse should check the tubing connections for leaks if there is bubbling in the water seal chamber and tighten them if necessary.
Choice B: Check the suction control outlet on the wall is not an action that the nurse should take. The suction control outlet on the wall is the source of negative pressure that helps drain fluid and air from the pleural space and maintain a patent chest tube. The suction control chamber is the part of the closed chest drainage system that regulates the amount of negative pressure applied to the chest tube. The nurse should check the suction control outlet on the wall if there is no bubbling in the suction control chamber and adjust it as prescribed.
Choice C: Continue to monitor the client's respiratory status is an action that the nurse should take. Slow, steady bubbling in the suction control chamber is an expected finding that indicates that the suction is working properly and that there are no leaks in the system. The nurse should continue to monitor the client's respiratory status and assess for signs of respiratory distress, such as dyspnea, tachypnea, cyanosis, or decreased oxygen saturation.
Choice D: Clamping the chest tube is not an action that the nurse should take. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition characterized by a buildup of air in the pleural space that compresses the lung and shifts the mediastinum. The nurse should only clamp the chest tube temporarily and briefly for specific purposes, such as changing or troubleshooting the drainage system, or as prescribed by the provider.
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