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 A
Explanation
Choice A Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.
Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.
Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.
Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.
Correct Answer is B
Explanation
The correct answer is: d. Brachial pulse in the right arm.
Choice A reason: Palpating the radial pulse in the right arm is not the most appropriate choice following a cardiac catheterization with a left antecubital insertion site. While it is contralateral to the insertion site, the brachial pulse is preferred over the radial pulse for assessing circulation in the arm, as it is more proximal and can provide a better indication of arterial flow from the catheterization site.
Choice B reason: The radial pulse in the left arm is the correct choice because it evaluates distal circulation in the affected limb. Since the catheterization was performed through the left antecubital fossa, it is crucial to monitor blood flow further down in the arm. Palpating the radial pulse helps detect early signs of compromised perfusion, such as diminished pulse strength. Evidence-based guidelines from clinical sources highlight the importance of distal pulse assessment post-catheterization.
Choice C reason: Palpating the brachial pulse in the left arm is also not recommended. Since the catheterization was performed on the left side, there is a risk of arterial occlusion or spasm, which could affect the accuracy of the pulse assessment in the left arm.
Choice D reason: The brachial pulse in the right arm does not provide relevant information about the left arm’s vascular status post-catheterization. Since the right arm was not affected by the procedure, its pulse does not indicate possible complications in the left arm. Clinical assessment should focus on detecting perfusion issues in the limb where the catheter was inserted. Best practices recommend prioritizing the evaluation of circulation in the affected extremity.
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