Chapter 10: Vital Signs and Laboratory Reference Intervals

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000mm3(2.0Â109/L) 2. 5800mm3(5.8Â109/L) 3. 8400mm3(8.4Â109/L) 4. 11,500mm3 (11.5Â109/L)

1 Rationale: The normal WBC count ranges from 5000- 10,000 mm3 (5-10Â109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values. Test-Taking Strategy: Focus on the subject, the need to implement neutropenic precautions. Recalling that the normal WBC count is 5000-10,000 mm3 (5-10Â109/L) will direct you to the correct option. Review: The normal adult white blood cell differential count

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potas- sium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2mEq/L(3.2mmol/L) 2. 3.8mEq/L(3.8mmol/L) 3. 4.2mEq/L(4.2mmol/L) 4. 4.8mEq/L(4.8mmol/L)

1 Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range. Test-Taking Strategy: Note the subject of the question, the level that should be reported. This indicates that you are looking for an abnormal level. Remember, the normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). This will direct you to the correct option. Review: The normal serum potassium level

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1,2,3 Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide. Test-Taking Strategy: Note the subject of the question, data provided by the client necessitating contacting the HCP. Deter- mining that ibuprofen is classified as an NSAID will help you to determine that it should not be combined with anticoagulants. Also recalling that hypoglycemia can occur as an adverse effect will help you to recall that these medications should not be combined. From the remaining options, it is necessary to remember that toxicity can result if NSAIDs are combined with calcium channel blockers. Review: Medication interactions for NSAIDs, specifically ibuprofen

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35Â109/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 μmol/L) 6. White blood cells, 3000 mm3(3.0Â109/L)

1,2,4,6 Rationale: The normal values include the following: platelets 150,000-400,000 mm3 (150-400 Â 109/L); sodium 135- 145 mEq/L (135-145 mmol/L); potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L); segmented neutrophils 60%-70% (0.60- 0.70); serum creatinine 0.6-1.3 mg/dL (53-115 μmol/L); and white blood cells 5000-10,000 mm3 (5.0-10.0 Â 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low. Test-Taking Strategy: Focus on the subject, the abnormal laboratory values that need to be reported. Recalling the normal laboratory values for the blood studies identified in the options will assist in answering this question. Review: The normal laboratory values

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic

2 Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to mea- sure the temperature on the neck behind the ear, avoiding the forehead. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect action as the answer. Recall that nasal congestion is a reason to avoid taking an oral temperature, as the nasal congestion will cause problems with breathing while the temperature is being taken. Review: Temperature measurement methods

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 3mg/dL(1.05mmol/L) 2. 15mg/dL(5.25mmol/L) 3. 29mg/dL(10.15mmol/L) 4. 35mg/dL(12.25mmol/L)

2 Rationale: The normal BUN level is 6 to 20 mg/dL (2.1 to 7.1 mmol/L). Values of 29 mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3mg/dL (1.05mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. Test-Taking Strategy: Focus on the subject, adequate fluid replacement and the normal BUN level. The correct option is the only option that identifies a normal value. Review: The normal blood urea nitrogen level

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 (35) seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2 Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect. Test-TakingStrategy: Focus on the subject, a PT of 35 seconds and an INR of 3.5. Recall the normal ranges for these values and remember that a PT greater than 32 seconds and an INR greater than 3 for standard warfarin therapy places the client at risk for bleeding; this will direct you to the correct option. Review: The normal prothrombin time and INR levels

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2 °F (36.2 °C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the health care provider (HCP) immediately. 4. Check the medication administration history on the PCA pump.

2 Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the cli- ent is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client. Test-Taking Strategy: First, note the strategic word, next. Focus on the data in the question and determine if an abnormality exists. It is clear that an abnormality exists because the client is drowsy and the vital signs are outside of the normal range. Recall that attempting to arouse the client should come before further assessment of the pump. The client should always be assessed before the equipment, before contacting the HCP, and before documentation. Review: Management of potential opioid overdose.

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

3 Rationale: The normal hemoglobin level for an adult female client is 12-16 g/dL (120-160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. Test-Taking Strategy: Note the strategic words, most likely. Evaluate each of the conditions in the options in terms of their pathophysiology and whether each is likely to raise or lower the hemoglobin level. Also, note the relationship between hemoglobin level in the question and the correct option. Review: The normal hemoglobin level

A client with a history of gastrointestinal bleeding has a platelet count of 300,000mm3 (300Â109/L). The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

4 Rationale: A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400Â109/L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300Â109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. Test-Taking Strategy: Focus on the subject, a platelet count of 300,000 mm3 (300 Â 109/L). Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options indicating to report the abnormally low count and placing the client on bleeding precautions first. From the remaining options, recalling the normal range for this laboratory test will direct you to the correct option. Review: The normal platelet count

A staff nurse is precepting a new graduatenurse and the new graduate is assigned to care fora client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10."2. "I know that I should follow up after giving medication to make sure it is effective." 3. "I know that pain in the older client might manifest as sleep disturbances or depression." 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

4 Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement as the answer. Recall that pain is a highly individual experience, and the nurse should not assume that the client is exaggerating pain. Review: Management of pain

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After not- ing that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

4 Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy. Test-Taking Strategy: Focus on the subject, a client who has taken an excessive dose of warfarin. Eliminate the option with a PTT first because it is unrelated to warfarin therapy and relates to heparin therapy. Next, eliminate the options indicating to administer an antidote and to transfuse the client because these therapies would not be implemented unless the PT and INR levels were known. Review: Care to the client receiving warfarin therapy

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds (65 seconds). The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4 Rationale: The normal aPTTvaries between 28 and 35 seconds (28 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42 to 52.5) and 2.5 (70 to 87.5) times normal. This means that the client's value should not be less than 42 seconds or greater than 87.5seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged. Test-Taking Strategy: Focus on the subject, the expected aPTT for a client receiving a heparin sodium infusion. Remember that the normal range is 28 to 35 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 28 and 35 will yield a range of 42 to 87.5 seconds). This client's value is 65 seconds Review: The aPTT level and the expected level if the client is receiving heparin

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4 Rationale: The normal reference range for the glycosylated hemoglobin A1c is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to he red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glu- cose for a glycosylated hemoglobin A1c of 9% is 212 mg/dL (11.8 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. Test-Taking Strategy: Focus on the subject, a glycosylated hemoglobin A1c level of 9%. Recalling the normal value and that an elevated value indicates hyperglycemia will assist in directing you to the correct option. Review: Glycosylated hemoglobin A1c