The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

White blood cell count (WBC).

Blood urea nitrogen (BUN).

Hematocrit.

Glucose.

Answer and Explanation

The Correct Answer is C

Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.

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Correct Answer is C

Explanation

A. Number of blood clots expelled with each stool.Thisis not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding.While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool.Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids.While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Palpation of the spinous processes and surrounding muscles are non-tender. D. Observation of cervical range of motion reveals flexion and extension is 25 degrees.

Correct Answer is D

Explanation

A. Inspection of head and neck is observed in a straight alignment without lateral curves: A straight, well-aligned cervical spine is normal and does not indicate a need for further assessment of lifestyle habits.

B. Evaluation of cranial nerve XI (spinal accessory nerve) reveals flexion is maintained against full resistance:This indicates normal strength of the sternocleidomastoid and trapezius muscles, meaning there is no concern related to lifestyle habits.

C. Palpation of the spinous processes and surrounding muscles are non-tender: The absence of tenderness suggests that there is no acute inflammation, injury, or muscle strain, making further lifestyle inquiries unnecessary.

D. Observation of cervical range of motion reveals flexion and extension is 25 degrees:Normal cervical flexion and extension range from 45 to 90 degrees. A limitation to only 25 degrees suggests restricted mobility, which could be due to poor posture, occupational strain, prolonged screen time, or underlying musculoskeletal conditions.

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The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating a client’s rectal bleeding, which findings should the nurse document?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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