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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A: Hct 45% is not a value that the nurse should report to the provider. Hct, or hematocrit, is the percentage of red blood cells in the total blood volume. The normal range for Hct is 37% to 51% for men and 32% to 45% for women. Hct 45% is within the normal range and does not indicate any abnormality.

Choice B: Platelets 160,000/mm³ is not a value that the nurse should report to the provider. Platelets, or thrombocytes, are cell fragments that help with blood clotting and hemostasis. The normal range for platelets is 150,000 to 450,000/mm³. Platelets 160,000/mm³ is within the normal range and does not indicate any abnormality.

Choice C: WBC 1,700/mm³ is a value that the nurse should report to the provider. WBC, or white blood cells, are cells that fight infection and inﬂammation. The normal range for WBC is 4,500 to 11,000/mm³. WBC 1,700/mm³ is below the normal range and indicates leukopenia, which is a low number of white blood cells. Leukopenia can be caused by various conditions, such as viral infections, autoimmune disorders, bone marrow suppression, or chemotherapy. Leukopenia can increase the risk of infection and sepsis and requires prompt evaluation and treatment.

Choice D: Hgb 14.7 g/dL is not a value that the nurse should report to the provider. Hgb, or hemoglobin, is a protein in red blood cells that carries oxygen to the tissues. The normal range for Hgb is 13.5 to 17.5 g/dL for men and 12.0 to 15.5 g/dL for women. Hgb 14.7 g/dL is within the normal range and does not indicate any abnormality.

A. The client can follow simple motor commands. B. The client opens his eyes when spoken to. C. The client is unconscious. D. The client is unable to make vocal sounds.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.

Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.

Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.

Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is C

Explanation

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