A nurse is reviewing the laboratory results for four clients. Which of the following results is the priority for the nurse to report to the provider?
WBC 11,000/mm² in a client who is starting treatment for a methicillin-resistant staphylococcus aureus (MRSA) infection.
Serum pH 7.25 in a client who has type 1 diabetes mellitus.
Hematocrit 26% in a client who has sickle cell disease.
Urine specific gravity 1.032 in a client who is diagnosed with dehydration.
The Correct Answer is B
Choice A rationale:
An elevated WBC count (11,000/mm²) in a client starting treatment for MRSA infection may indicate an inflammatory response, but it is expected in this scenario, and the priority is not as high as other critical lab values.
Choice B rationale:
A serum pH of 7.25 indicates acidosis, which is a potentially life-threatening condition. In type 1 diabetes mellitus, diabetic ketoacidosis (DKA) is a common complication that can lead to metabolic acidosis. This lab result is a priority as it requires immediate attention.
Choice C rationale:
Hematocrit of 26% in a client with sickle cell disease might be low, but it is not the priority over the critically abnormal lab value of serum pH in option B.
Choice D rationale:
A urine specific gravity of 1.032 in a client diagnosed with dehydration is elevated, indicating concentrated urine due to dehydration. While dehydration is concerning, it is not as high-priority as the potentially life-threatening acidosis in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.
Choice B rationale:
Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.
Choice C rationale:
The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.
Choice D rationale:
Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.
Correct Answer is A
Explanation
Choice A rationale:
Testicular cancer may present as a painless lump or swelling in the testicle. It's important for the client to monitor for any new or unusual lumps, as they could be indicative of cancer.
Choice B rationale:
A decreased size of the testicle is not a typical manifestation of testicular cancer. It is more commonly associated with conditions like testicular atrophy due to other causes.
Choice C rationale:
Asymmetry in the position of the testicles, with one testicle descending lower than the other, is a normal variation and not a sign of testicular cancer.
Choice D rationale:
Dilated veins above the testicle can be a sign of a varicocele, which is a separate condition from testicular cancer. It is caused by abnormal enlargement of veins in the scrotum and is generally not associated with cancer.
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