An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Protein.

Hemoglobin.

White blood cell count

Sodium.

Answer and Explanation

The Correct Answer is D

A.   While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B.   Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C.   The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D.   Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

A. Egg whites, toast, and coffee. B. Bran muffin, mixed fruit, and orange juice. C. Granola bar and grapefruit juice. D. Bagel with jelly and skim milk.

Correct Answer is B

Explanation

A. While this breakfast is healthy and nutritious, it does not contain significant amounts of calcium or vitamin D, which are essential for bone health.
B. Bran muffins, mixed fruit, and orange juice are all good sources of calcium and vitamin D, two essential nutrients for bone health. A diet rich in calcium and vitamin D is recommended for individuals with osteoporosis to help strengthen bones and reduce the risk of fractures.
C. While granola bars and grapefruit juice can be healthy, they may not provide enough calcium and vitamin D to meet the nutritional needs of a client with osteoporosis.
D. While skim milk is a good source of calcium, the bagel and jelly do not provide significant amounts of calcium or vitamin D.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Correct Answer is B

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?