A nurse is evaluating the laboratory findings of a client who has wound dehiscence following abdominal surgery. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Potassium 3.5 mEq/L
Sodium 145 mEq/L
Hematocrit 53%
HbA1c 5%
The Correct Answer is C
Choice A reason: Potassium 3.5 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 3.5 to 5.0 mEq/L. Potassium is an electrolyte that regulates nerve and muscle function, acid-base balance, and fluid balance. Potassium level can be affected by various factors, such as diet, medication, kidney function, and dehydration.
Choice B reason: Sodium 145 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 136 to 145 mEq/L. Sodium is an electrolyte that regulates blood pressure, blood volume, and fluid balance. Sodium level can be affected by various factors, such as diet, medication, kidney function, and fluid loss.
Choice C reason: Hematocrit 53% is a finding that indicates fluid volume deficit because it is above the normal range, which is 38 to 50% for men and 34 to 46% for women. Hematocrit is the percentage of red blood cells in the total blood volume. Hematocrit level can increase due to dehydration, which causes hemoconcentration or increased blood viscosity.
Choice D reason: HbA1c 5% is not a finding that indicates fluid volume deficit because it is within the normal range, which is less than 5.7%. HbA1c is the percentage of hemoglobin that is attached to glucose. HbA1c level reflects the average blood glucose level over the past two to three months. HbA1c level can be affected by various factors, such as diabetes, anemia, and medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Tuna fish is a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is soft, moist, and easy to swallow. Tuna fish also provides protein, omega-3 fatty acids, and vitamin D for the client.
Choice B reason: Roast beef is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has missing teeth. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
Choice C reason: Apple slices are not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are crisp, firm, and sticky. Apple slices can cause irritation or injury to the gums or mouth or dislodge any remaining teeth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Choice D reason: Dried fruit is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are chewy, sticky, and sugary. Dried fruit can adhere to the gums or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
Correct Answer is A
Explanation
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
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