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 B

Explanation

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

A. Translucent, pearly gray and mobile tympanic membrane. B. Red, edematous ear canal with no visualization of the tympanic membrane. C. Thickened and bulging tympanic membrane. D. Retracted and non-mobile tympanic membrane.

Correct Answer is B

Explanation

Choice A rationale
A translucent, pearly gray, and mobile tympanic membrane is a normal finding and does not align with the symptoms of itching, pain, and discharge.
Choice B rationale
A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as “swimmer’s ear.”. This condition is characterized by inflammation and infection of the external ear canal, often following swimming.
Choice C rationale
A thickened and bulging tympanic membrane is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum.
Choice D rationale
A retracted and non-mobile tympanic membrane is typically associated with eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described.

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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?

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Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, “My feet swell all the time?”

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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