The nurse is assessing an older female adult's client's nutritional status. Which finding indicates that the client has a nutritional deficiency?

Reference Ranges:

Hemoglobin [12 to 16 g/dl (120 to 160 g/L)]

Hematocrit 37% to 47% (0.37 to 0.47 volume fraction)]

Albumin [3.5 to 5.0 g/dl (35 to 50 g/L)]

Serum transferrin [250 to 380 mg/dl (2.5 to 3.80 g/L)]

A hemoglobin (Hgb) of 11.8 g/dL (118 g/L) and hematocrit (Hct) of 34% (0.34).

Low weight as determined from a height/weight comparison chart.

Decreased lean body mass compared to results of 10 years ago.

Serum albumin of 3 g/dL (30 g/L) and serum transferrin of 180 mg/dL (1.8 g/L).

Answer and Explanation

The Correct Answer is D

A.   Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B.   Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C.   A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D.   Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

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Correct Answer is ["A","B","D","E"]

Explanation

A. This device can be used to summon help quickly in case of a fall or other emergency.
B. Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C. Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D. Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E. A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

A. Document the color and clarity of the urine. B. Inflate the balloon with 5 mL of sterile water. C. Ask the client to breathe deeply and slowly exhale. D. Insert the catheter an additional inch.

Correct Answer is B

Explanation

A. While documenting the color and clarity of the urine is important for assessing the client's urinary output and potential issues, it is not the immediate next step in the catheter insertion process. This step typically comes after the catheter is fully inserted and secured.
B. Once urine flow is observed, the next step is to inflate the balloon of the indwelling catheter to secure it in place within the bladder. This ensures the catheter remains correctly positioned and does not move out of the bladder, which is crucial for effective drainage and preventing accidental dislodgement.
C. Asking the client to breathe deeply and exhale does not impact the catheterization process and is not related to the next immediate step after observing urine flow. This action might be helpful in other contexts, such as reducing anxiety or discomfort, but it does not address the technical steps required for catheter insertion.
D. If urine flow is observed in the catheter, it indicates that the catheter is already in the bladder. Inserting the catheter an additional inch is unnecessary and could potentially cause trauma or discomfort. Proper catheter placement is confirmed by the observation of urine flow, and additional insertion is not required.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D","E"]

Explanation

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Correct Answer is B

Explanation

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