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.

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Correct Answer is A

Explanation

A. Encouraging the spouse to share their feelings is the most appropriate initial action. It provides an opportunity for the spouse to express their emotions and begin processing their grief. This approach validates the spouse’s feelings, offers emotional support, and establishes a supportive environment where the spouse can feel heard and understood.
B. Offering reassurance that the spouse is not alone can be comforting, but it may not fully address the immediate emotional needs of the spouse. It is important to first allow the spouse to express their feelings and then provide reassurance as part of the ongoing support.
C. Discussing alternative treatment options may be premature and could be perceived as dismissive of the spouse’s immediate emotional response. At this moment, the spouse is focused on the emotional impact of the terminal diagnosis rather than treatment options.
D. While offering hope can be part of supportive care, this approach might unintentionally minimize the spouse’s current feelings of loss and grief. It can also come across as dismissive of the immediate emotional impact of the diagnosis.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Capillary refill time is 2 seconds. D. Radial pulse volume is 3+.

Correct Answer is B

Explanation

A. Elevated blood pressure can be a concern for overall cardiovascular health but it does not directly affect the accuracy of pulse oximetry readings.
B. Edema, or swelling, of the fingers and hands can affect the accuracy of pulse oximeter readings. Edema can impede proper light transmission through the finger, leading to falsely low oxygen saturation readings.
C. A capillary refill time of 2 seconds is within normal limits, indicating adequate peripheral perfusion. It is unlikely to affect pulse oximeter readings significantly, so this is not a likely cause of a low oxygen saturation reading.
D. A radial pulse volume of 3+ indicates a strong, full pulse. This finding typically suggests good peripheral circulation and is not likely to impact the accuracy of pulse oximetry readings.

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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

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

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When identifying the goals to be included in a client's plan of care, the nurse should take which action?

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