Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Hemoglobin = 14.2 g/dL.

Potassium = 4.2 mEq/L.

Albumin = 2.8 g/dL.

Creatinine = 0.8 mg/dL.

Answer and Explanation

The Correct Answer is C

Albumin is a protein that is made by the liver and helps maintain fluid balance in the

body. The normal range for albumin is 3.5 to 5.5 g/dL or 35-55 g/liter. A low albumin level can indicate malnutrition, liver disease, kidney disease, inflammation, or other conditions that affect protein synthesis or loss.

A client diagnosed with Imbalanced Nutrition: Less than Body Requirements would be expected to have a low albumin level due to inadequate protein intake or absorption.

Choice A is wrong because hemoglobin = 14.2 g/dL is within the normal range for males, which is 13.2 to 16.6 g/dL.

Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. A low hemoglobin level can indicate anemia, which can be caused by blood loss, iron deficiency, vitamin B12 deficiency, or other conditions that affect red blood cell production or destruction.

Choice B is wrong because potassium = 4.2 mEq/L is within the normal range for adults, which is 3.5 to 5 mEq/L.

Potassium is an electrolyte that helps regulate fluid balance, nerve impulses, and muscle contractions. A low potassium level can indicate dehydration, diarrhea, vomiting, diuretic use, or other conditions that cause potassium loss. A high potassium level can indicate kidney disease, adrenal insufficiency, acidosis, or other conditions that cause potassium retention.

Choice D is wrong because creatinine = 0.8 mg/dL is within the normal range for adults, which is 0.6 to 1.2 mg/dL.

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Correct Answer is D

Explanation

Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.

Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.

Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.

Taking the client’s temperature again does not involve working with other disciplines.

Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.

Taking the client’s temperature again does not require a physician’s order.

Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.

Taking the client’s temperature again does not require collaboration with other disciplines.

A. Monitor the urine’s color and odor. B. Record the intake and output every eight hours. C. Irrigate the tube with 30 mL of sterile saline as needed. D. Measure the vital signs every four hours during the day.

Correct Answer is C

Explanation

Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.

Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.

Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.

Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.

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Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

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Naxlex Comprehensive Predictor Exams

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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