FUNDS EXIT HESI REVIEW

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? A. Assess tube placement. B. Flush with 30 mL of sterile saline. C. Aspirate to determine residual volume. D. Administer the antacid by gravity flow.

A. Assess tube placement. Although each of the actions in the options is important, evaluation of tube placement is the priority to prevent aspiration and to ensure that medication delivery will be in the stomach.

The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition? A. Hepatic disease B. Cirrhosis of the liver C. Factor VII deficiency D. Deep vein thrombosis

D. Deep vein thrombosis The normal PT for an adult ranges from 11 to 12.5 seconds. A decreased PT may be noted in many conditions, including arterial occlusion, deep vein thrombosis, edema, myocardial infarction, peripheral vascular disease, and pulmonary embolism. An increased PT would be noted in the conditions identified in the remaining options.

The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate? A. Low B. Normal C. Slightly elevated and needs referral D. Very high, indicating severe renal failure

D. Very high, indicating severe renal failure The normal serum creatinine level for an adult male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). A creatinine level of 4.0 mg/dL (353 mcmol/L) is a critical value and indicates serious impairment in renal function. This value is not low, normal, or slightly elevated.

The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition? A. Aplastic anemia B. Sickle cell anemia C. Infectious mononucleosis D. Acute lymphocytic leukemia

B. Sickle cell anemia Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of Hgb S. The client must have 2 abnormal genes encoding Hgb S to have sickle cell disease. A client could have sickle cell trait by carrying 1 hemoglobin A gene and 1 Hgb S gene. Hgb S is not associated with aplastic anemia, infectious mononucleosis, or acute lymphocytic leukemia.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which value is noted? A. 70,000 mm3 (70 × 109/L) B. 110,000 mm3 (110 × 109/L) C. 160,000 mm3 (160 × 109/L) D. 500,000 mm3 (500 × 109/L)

C. 160,000 mm3 (160 × 109/L) A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). Values of 70,000 and 110,000 mm3 (70 and 110 × 109/L) identify decreased values. A value of 500,000 mm3 (500 × 109/L) is an elevated value.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results? A. 1.001 B. 1.003 C. 1.019 D. 1.036

C. 1.019 The normal range for urine specific gravity is between 1.005 and 1.030. Values of 1.001 and 1.003 represent low values, and 1.036 reflects an elevated value.

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? A. A normal T4 level B. An elevated T4 level C. An elevated TSH level D. A decreased TSH level

C. An elevated TSH level Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed.

1. Close the roller clamp on the IV tubing. 2. Spike the IV bag and half-fill the drip chamber 3. Open the roller clamp and fill the tubing 4. Uncap the distal end of the tubing 5. Attach the distal end of the tubing to the client

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure?

1. Place the client in a semi Fowler's position 2. Turn on the suction device and set the regulator at 80 mm Hg. 3. Attach the suction tubing to the suction catheter. 4. Hyperoxygenate the client. 5. Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. 6. Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? A. "Take a deep breath when I tell you, and hold it while I remove the tube." B. "Take a deep breath when I tell you, and bear down while I remove the tube." C. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." D. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

A. "Take a deep breath when I tell you, and hold it while I remove the tube." The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath while the tube is removed. The nurse should remove the tube slowly and evenly over the course of 3 to 6 seconds. Bearing down could inhibit the removal of the tube. Exhaling and breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? A. Ensure that a sterile safety pin is through the drain. B. Measure the amount of drainage in a measuring container. C. Establish that the drain is at the prescribed amount of suction. D. Squeeze the suction device and close the port after emptying the drain.

A. Ensure that a sterile safety pin is through the drain. A Penrose drain is a soft, flat, flexible drain in which one end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus should have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound. Thus, option 1 is the correct option. Options 2, 3, and 4 are incorrect, as a Penrose drain is an open drainage system with no suction and it drains onto the skin or into a dressing, not into a collection container, so the amount of drainage cannot be measured in a measuring container.

The nurse is monitoring the client with a serum calcium level of 6.2 mg/dL (1.55 mmol/L). Which findings should the nurse assess for in the client? Select all that apply. A. Irritability B. Muscle cramps C. Tingling sensations D. Hyperactive reflexes E. Memory impairment F. Severe muscle weakness

A. Irritability B. Muscle cramps C. Tingling sensations D. Hyperactive reflexes E. Memory impairment Begin by recalling the normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L) to determine that the client is experiencing hypocalcemia. Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau's or Chvostek's sign. Other signs include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Severe muscle weakness is seen in hypercalcemia, not hypocalcemia.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? A. Stop the irrigation temporarily. B. Increase the height of the irrigation. C. Notify the health care provider (HCP). D. Medicate for pain and resume the irrigation.

A. Stop the irrigation temporarily. If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The HCP does not need to be notified. Medicating the client for pain is not the appropriate action in this situation.

A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time? A. 1 hour before administration of the scheduled dose B. 1.5 hours after completion of the scheduled infusion C. Immediately after administration of the scheduled dose D. 30 minutes before administration of the scheduled dose

B. 1.5 hours after completion of the scheduled infusion Peak serum medication levels should be monitored to ensure that the dosage is appropriate and should be drawn 1.5 to 2.5 hours after the intravenous infusion is completed. Peak levels of 30 to 40 mcg/mL generally are acceptable. Options 1, 3, and 4 are incorrect.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum lipase level is normal if which value is noted on the laboratory report? A. 4 U/L (4 U/L) B. 100 U/L (100 U/L) C. 210 U/L (210 U/L) D. 360 U/L (360 U/L)

B. 100 U/L (100 U/L) The normal serum lipase level is 0 to 160 U/L (0 to 160 U/L). The remaining options reflect either low or elevated serum lipase levels.

The nurse just completed an assessment and reviewed the laboratory test results for an adult female client seen in the clinic. The client complains of being tired. The nurse determines that the hemoglobin level is normal if which value is noted on the laboratory report? A. 8 g/dL (80 mmol/L) B. 14 g/dL (140 mmol/L) C. 22 g/dL (220 mmol/L) D. 32 g/dL (320 mmol/L)

B. 14 g/dL (140 mmol/L) The normal hemoglobin level for an adult female is 12 to 16 g/dL (120 to 160 mmol/L). A hemoglobin level of 8 g/dL (80 mmol/L) is low, while 22 and 32 g/dL (220 and 320 mmol/L) are extremely elevated.

An adult client with a history of seizure disorder is having a routine serum phenytoin level drawn. Which serum phenytoin result indicates that the client is having a therapeutic effect of the medication? A. 6 mcg/mL (23.8 mcmol/L) B. 16 mcg/mL (63.4 mcmol/L) C. 28 mcg/mL (110.9 mcmol/L) D. 36 mcg/mL (142.6 mcmol/L)

B. 16 mcg/mL (63.4 mcmol/L) The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL (39.6 to 79.2 mcmol/L). A level below the therapeutic range could place the client at risk for seizures. If a level is too high, the client is at risk for toxicity. At levels above 20 mcg/mL (79.2 mcmol/L), toxicity can occur with nystagmus, sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report? A. 4 mg/dL (1.4 mmol/L) B. 20 mg/dL (7.1 mmol/L) C. 30 mg/dL (10.7 mmol/L) D. 39 mg/dL (14.0 mmol/L)

B. 20 mg/dL (7.1 mmol/L) The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L). A BUN of 30 or 39 mg/dL (10.7 or 14.0 mmol/L) reflects an elevated value, while 4 mg/dL (1.4 mmol/L) reflects a lower than normal value.

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal? A. 170 mg/dL (1.7 g/L) B. 400 mg/dL (4.0 g/L) C. 480 mg/dL (4.8 g/L) D. 500 mg/dL (5.0 g/L)

B. 400 mg/dL (4.0 g/L) The normal fibrinogen level is 200 to 400 mg/dL (2 to 4 g/L). With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. The correct option is the only one that identifies a normal level.

The nurse is reviewing the laboratory test results for an adult male client seen in the health care clinic. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report? A. 58% (0.58) B. 50% (0.50) C.40% (0.40) D.32% (0.32)

B. 50% (0.50) The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52 volume fraction). A hematocrit of 58% (0.58) is a high level, whereas 40% and 32% are low hematocrit levels.

The nurse is reviewing the laboratory test results for a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this value would be noted in which condition? A. Diarrhea B. Addison's disease C. Diabetes insipidus D. Dumping syndrome

B. Addison's disease The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Many pathological conditions, including Addison's disease, adrenocortical insufficiency, anemia, burns, and ketoacidosis, result in an increased potassium level. Hyperkalemia can also cause abdominal cramping and diarrhea. The conditions in the remaining options would result in a decreased serum potassium level.

A client's nasogastric feeding tube has become clogged. The nurse should take which action first? A. Replace the tube. B. Aspirate the tube. C. Flush with carbonated liquids. D. Flush the tube with warm water.

B. Aspirate the tube. The first step in attempting to unclog a feeding tube is gently aspirating the tube. If this is not successful, flushing the tube with warm water can be tried. Carbonated liquids sometimes are used for flushing a clogged tube (depending on agency policy and procedures), but the tube must be rinsed thoroughly afterward to avoid stickiness. Replacement of the tube is the last step if other actions are unsuccessful. Also, the health care provider may prescribe another method of alleviating the obstruction.

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure? A. Half-inch tape B. Oil-soluble lubricant C. A 50-mL catheter tip syringe D. A glass of tap water with a straw

B. Oil-soluble lubricant Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to help verify placement. Only a chest x-ray can confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value? A. 8 mcg/mL (44 mcmol/L) B. 2.9 mcg/mL (50 mcmol/L) C. 18 mcg/mL (100 mcmol/L) D. 26 mcg/mL (144 mcmol/L)

C. 18 mcg/mL (100 mcmol/L) The therapeutic range for serum theophylline is 10 to 20 mcg/mL (55.5 to 111 mcmol/L). If the level is less than the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Values of 8 and 9 mcg/dL (44 and 50 mcmol/L) indicate low values, while 26 mcg/dL (144 mcmol/L) indicates an elevated value.

Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications? A. Presence of asterixis B. Increasing prothrombin time values C. Decrease in aspartate aminotransferase (AST) D. Decreased absorption of vitamin K in the intestine

C. Decrease in aspartate aminotransferase (AST) Complications from viral hepatitis include bleeding tendencies with increasing prothrombin time values and abnormalities of liver function. Clients also can develop encephalopathy. A characteristic sign of encephalopathy is asterixis. Serum transaminase levels such as AST decrease, and vitamin K becomes absorbed as liver cells heal and regenerate.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding? A. Supine B. Flat on the left side C. Fowler's on the right side D. Semi Fowler's on the left side

C. Fowler's on the right side Following a tube feeding, the head of the bed should be elevated for 30 to 60 minutes to prevent vomiting and aspiration, a complication of a tube feeding. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat supine position should be avoided after a tube feeding.

The nurse is reviewing the client's results of preadmission laboratory studies for a complete blood count, electrolytes, coagulation studies, and creatinine before a surgical procedure. Which laboratory result should the nurse report immediately to the surgeon? A. Platelet count 210,000 mm3 (210 x 109/L) B. Serum creatinine level 0.8 mg/dL (71 mcmol/L) C. Hemoglobin (Hgb) level 8.9 g/dL (89 mmol/L) D. Serum sodium level 141 mEq/L (141 mmol/L)

C. Hemoglobin (Hgb) level 8.9 g/dL (89 mmol/L) Routine screening tests include a complete blood count, coagulation studies, and serum electrolyte and creatinine levels. The complete blood count includes the Hgb analysis. All of these values are within normal range except for the Hgb level. If a client has a low Hgb level, the surgery could likely be postponed by the surgeon.

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess? A. Hepatitis B virus DNA B. Prolonged prothrombin time C. Hepatitis B surface antigen (HBsAg) D. Antibody to surface antigen (anti-HBs)

C. Hepatitis B surface antigen (HBsAg) HBsAg is present in chronic carriers. Hepatitis B virus DNA indicates viral replication. A prolonged prothrombin time is caused by decreased absorption of vitamin K in the intestine with decreased production of prothrombin by the liver. Anti-HBs is a marker for the response to the vaccine and indicates immunity to hepatitis B.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? A. Right side B. Low Fowler's C. High Fowler's D. Supine with the head flat

C. High Fowler's During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem? A. Infection B. Malnutrition C. Iron deficiency D. Sickle cell disease

C. Iron deficiency Iron deficiency anemia usually is characterized by decreased iron-binding capacity and increased transferrin saturation. Infection is not associated with these laboratory values. Malnutrition can cause reductions in both iron-binding capacity and transferrin saturation. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S.

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? A. Dehydration B. Heart failure C. Iron deficiency anemia D. Chronic obstructive pulmonary disease

C. Iron deficiency anemia 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.

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube? A. Placing the NG tube in warm water B. Hyperextending the head to insert the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced

D. Asking the client to swallow as the tube is being advanced To facilitate insertion best, when the tube reaches the pharynx, the client is encouraged to lower the head slightly, swallow and, if allowed, take sips of water. The NG tube would be iced to stiffen it, which eases insertion. If resistance is met, the tube is withdrawn and repassed. The correct option is the only one that would facilitate insertion.

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 noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer an antidote. B. Draw a sample for type and crossmatch and transfuse the client. C. Draw a sample for an activated partial thromboplastin time (aPTT) level. D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 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.

The nurse notes that a client's lithium level is 3.9 mEq/L (3.9 mmol/L). What is the nurse's priority action in response to this finding? A. Determining visual acuity B. Assisting with ambulation C. Monitoring intake and output D. Instituting seizure precautions

D. Instituting seizure precautions A therapeutic regimen aims at a serum lithium level of 1.0 to 1.5 mEq/L (1.0 to 1.5 mmol/L) during acute mania and levels of 0.6 to 1.4 mEq/L (0.6 to 1.4 mmol/L) for maintenance treatment. A level of 3.9 mEq/L (3.9 mmol/L) is in the toxic range, and seizures may occur at levels of 3.5 mEq/L (3.5 mmol/L) and higher. Options 1, 2, and 3 are indicated, but none of these is the priority intervention.

The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action? A. Remove the tube, and notify the health care provider. B. Instruct the client to hold his breath, and insert the NG tube. C.Remove the tube, and reinsert when the client fully recovers. D. Pull back on the tube, and wait until the client is breathing easily.

D. Pull back on the tube, and wait until the client is breathing easily. If the client experiences difficulty breathing or any respiratory distress during insertion of an NG tube, the nurse would pull back the tube and wait until the distress subsides. Options 1 and 3 describe actions that are unnecessary. Option 2 is dangerous because it is likely that the tube has entered the bronchus.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? A. Band-Aid B. Alcohol swab C. Povidone-iodine swab D. Sterile 2 × 2 gauze

D. Sterile 2 × 2 gauze A dry sterile dressing, such as sterile 2 × 2 gauze, is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A povidone-iodine swab or alcohol swab would irritate the opened puncture site and would not stop the blood flow. A Band-Aid may be used to cover the site after hemostasis has occurred.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted? A. 110 mg/dL (6 mmol/L) B. 120 mg/dL (6.9 mmol/L) C.130 mg/dL (7.4 mmol/L) D. 4.140 mg/dL (8 mmol/L)

A. 110 mg/dL (6 mmol/L) The normal fasting blood glucose is 70 to 110 mg/dL (4 to 6 mmol/L) in the adult client. The results in the remaining options indicate elevated fasting serum glucose levels.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation? A. Tap water B. Sterile water C. Sterile distilled water D. Sterile lactated Ringer's

A. Tap water Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, bottled water should be used. The other options are incorrect solutions.

A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion? A. Protein level of 72 g/L (7.2 g/dL) B. Ammonia level of 98 mcg/dL (60 mcmol/L) C. Magnesium level of 1.7 mEq/L (0.85 mmol/L) D. Total bilirubin level of 1.2 mg/dL (20.5 mcmol/L)

Ammonia level of 98 mcg/dL (60 mcmol/L) The normal serum ammonia level ranges from 10 to 80 mcg/dL (6 to 47 mcmol/L). High levels of ammonia can result in encephalopathy and coma. The other blood levels are not related to hepatic encephalopathy and are also normal values.

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? A. 3 mg/dL (1.05 mmol/L) B. 15 mg/dL (5.25 mmol/L) C. 29 mg/dL (10.15 mmol/L) D. 35 mg/dL (12.25 mmol/L)

B. 15 mg/dL (5.25 mmol/L) 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 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? A. Palpation and clubbing B. Percussion and vibration C. Hyperoxygenation and suctioning D. Administer a bronchodilator and monitor peak flow

B. Percussion and vibration Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

A client who has a serum potassium (K+) level of 2.9 mEq/L (2.9 mmol/L) tells the nurse that he does not feel like eating lunch. The nurse checks his serum digoxin level from that morning and notes that it is 1.0 ng/mL (1.2 nmol/L). What should the nurse determine about this digoxin level? A. Low B. Extremely toxic C. Within the therapeutic range D. Just above the high end of the therapeutic range

D. Just above the high end of the therapeutic range Digoxin is a cardiac glycoside that is used to treat dysrhythmias such as atrial fibrillation in clients with heart failure. Digoxin blood levels need to be checked while the client is taking this medication to monitor for toxicity. The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). Therefore, a blood level of 1.0 ng/mL (1.2 nmol/L) is just above the high end of the therapeutic range. It is important to be aware that a low K+ level has an additive effect in increasing the risk of digoxin toxicity. The normal K+ level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

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. The nurse anticipates that which action is needed? A. Discontinuing the heparin infusion B. Increasing the rate of the heparin infusion C.Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

D. Leaving the rate of the heparin infusion as is The normal aPTT varies 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 87.5 seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition? A. Dehydration B. Iron deficiency C. Severe diarrhea D. Polycythemia vera

Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. A decrease in the RBC count also may be noted in the older client. Increased RBC counts are noted in clients with the disorders in the remaining options.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse reports to the client that the total cholesterol level is within the recommended guidelines if which value is noted on the laboratory report? A. 146 mg/dL (4 mmol/L) B. 224 mg/dL (6 mmol/L) C. 256 mg/dL (7 mmol/L) D. 301 mg/dL (8 mmol/L)

A. 146 mg/dL (4 mmol/L) The client should be counseled to keep the total cholesterol level under 200 mg/dL (under 5 mmol/L) or even lower as recommended by the health care provider. Controlling cholesterol levels will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? A. "Take a deep breath when I tell you, and hold it while I remove the tube." B. "Take a deep breath when I tell you, and bear down while I remove the tube." C. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." D. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

A. "Take a deep breath when I tell you, and hold it while I remove the tube." The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30% (0.30). Which action should the nurse take? A. Report the abnormally low level. B. Report the abnormally high level. C.Inform the client that the laboratory result is normal. D. Place the normal report in the client's medical record.

A. Report the abnormally low level. The normal hematocrit level ranges from 42% to 52% (0.42 to 0.52) in a male and from 37% to 47% (0.37 to 0.47) in a female, depending on age. A hematocrit level of 30% (0.30) is a low level and would be reported to the health care provider because it indicates blood loss. Therefore, the remaining options are incorrect.

The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply. A. The total number of WBCs B. An increased number of bands C. The presence of an acute infectious process D. An increased number of mature neutrophils E.An increased number of immature neutrophils

A. The total number of WBCs B. An increased number of bands C. The presence of an acute infectious process E.An increased number of immature neutrophils The differential count reflects the percentage of the total number of WBCs. A left shift indicates an increased number of immature neutrophils, or an increased number of bands. This signals the presence of an acute infectious process. A right shift represents an increased number of mature neutrophils.

The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)? A. "A reticulocyte is a mature RBC." B. "A reticulocyte is an immature RBC." C. "A reticulocyte is decreased whenever there is accelerated production of RBCs." D. "A reticulocyte is increased when the bone marrow has slowed production of RBCs."

B. "A reticulocyte is an immature RBC." The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs.

The nurse checks the laboratory results of a serum medication level assay for a newly admitted client taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level? A. 0.1 ng/mL (0.13 nmol/L) B. 0.6 ng/mL (0.76 nmol/L) C. 1.8 ng/mL (2.30 nmol/L) D. 2.4 ng/mL (3.07 nmol/L)

B. 0.6 ng/mL (0.76 nmol/L) The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A value of 0.6 ng/mL (0.76 nmol/L) falls within the therapeutic range, and the medication would be continued as at home. A values of 0.1 (0.13 nmol/L) is lower than the therapeutic range and would require additional medication to be given. A value of 1.8 ng/mL (2.30 nmol/L) and 2.4 ng/mL (3.07 nmol/L) exceeds the therapeutic range, could be toxic to the client, and would be held.

A client is donating blood for a family member who is having surgery. The nurse tells the client that an indirect Coombs' test will be performed on the blood. The client asks the nurse about the purpose of the test. Which response should the nurse provide to the client? A. "The test detects the presence of hepatitis B virus." B. "The test detects the amount of hemoglobin in the blood." C. "The test detects circulating antibodies against red blood cells (RBCs)." D. "The test detects the presence of human immunodeficiency virus (HIV)."

C. "The test detects circulating antibodies against red blood cells (RBCs)." The indirect Coombs' test detects circulating antibodies against RBCs. This test is used in addition to the ABO typing that normally is done to determine blood type. The indirect Coombs' test does not detect the presence of hepatitis B virus, amount of hemoglobin in the blood, or the presence of HIV.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum protein level is normal if which value is noted on the laboratory report? A. 0.9 g/dL (9 g/L) B. 2.2.7 g/dL (27 g/L) C. 7.0 g/dL (70 g/L) D. 9.2 g/dL (92 g/L)

C. 7.0 g/dL (70 g/L) The normal range for the serum protein level in the adult client is 6.4 to 8.3 g/dL (64 to 83 g/L). Values of 0.9 and 2.7 g/dL (9 and 27 g/L) identify low protein levels, while a value of 9.2 g/dL (92 g/L) identifies an elevated protein level.

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report? A. 2000 mm3 (2 × 109/L) B. 3600 mm3 (3.6 × 109/L) C. 8600 mm3 (8.6 × 109/L) D. 13,500 mm3 (13.5 × 109/L)

C. 8600 mm3 (8.6 × 109/L) The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). Values of 2000 and 3600 mm3 (2 and 3.6 × 109/L) indicate low values, while 13,500 mm3 (13.5 × 109/L) indicates an elevated value.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? A. Position the client supine to assist in medication absorption. B. Aspirate the nasogastric tube after medication administration to maintain patency. C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. D. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

A client with cirrhosis is being treated for hypernatremia. On reviewing the laboratory values for the client, the nurse determines that treatment is effective if which laboratory result is noted? A. Urine specific gravity of 1.040 B. Serum sodium value of 150 mEq/L (150 mmol/L) C. Serum sodium value of 145 mEq/L (145 mmol/L) D. Serum osmolality of 300 mOsm/kg (300 mmol/kg)

C. Serum sodium value of 145 mEq/L (145 mmol/L) Laboratory data reflective of hypernatremia include a serum sodium value greater than 148 mEq/L (148 mmol/L), serum osmolality greater than 295 mOsm/kg (295 mmol/kg), and urine specific gravity greater than 1.030 when the kidneys are functioning normally. The increase in the urine specific gravity is a result of the compensatory attempt by the kidneys to conserve water. Normal serum sodium levels range from 135 mEq/L to 145 mEq/L (135 to 145 mmol/L). The serum sodium level of 145 mEq/L (145 mmol/L) is the only normal value, indicating that treatment is effective.

The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply. A. Laxatives B. Stool softeners C.Anabolic steroids D. Oral contraceptives E. Non-steroidal anti-inflammatory drugs

C.Anabolic steroids D. Oral contraceptives E. Non-steroidal anti-inflammatory drugs The normal sodium level for an adult client is 135 to 145 mEq/L. Some medications are known to increase sodium levels, and these medications include anabolic steroids, oral contraceptives, and nonsteroidal antiinflammatory drugs.

The nurse is reviewing the electrolyte panel results for an assigned client who is taking a potassium supplement. The nurse should determine that a therapeutic effect is present if which value is noted? A. 2.8 mEq/L (2.8 mmol/L) B. 3.0 mEq/L (3.0 mmol/L) C. 3.3 mEq/L (3.3 mmol/L) D. 4.0 mEq/L (4.0 mmol/L)

D. 4.0 mEq/L (4.0 mmol/L) The normal serum potassium level for an adult client is approximately 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The values in options 1, 2, and 3 are incorrect because they are low.

The nurse is reviewing the laboratory results of a serum medication level assay for a client seen in the health care clinic who has been taking phenytoin for the control of seizures. The nurse determines that a subtherapeutic level of phenytoin is present and that additional medication is required if which level is found? A. 3 mcg/mL (12 mcmol/L) B. 2.16 mcg/mL (63 mcmol/L) C. 3.18 mcg/mL (71 mcmol/L) D. 4.24 mcg/mL (95 mcmol/L)

A. 3 mcg/mL (12 mcmol/L) The therapeutic range for a serum phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). A level of 3 mcg/dL (12 mcmol/L) is subtherapeutic and would indicate the need for additional medication. If the level is less than the therapeutic range, the client may continue to experience seizure activity. The level in option 4 is high. If the level is too high, the client could experience phenytoin toxicity.

A client with a diagnosis of hyperphosphatemia has been treated with dietary management and phosphate-binding gels. The client reports to the clinic, and the nurse is reviewing the laboratory results. Which reported serum phosphate level would indicate improvement in the client's condition? A. 4.0 mg/dL (1.3 mmol/L) B. 5.2 mg/dL (1.7 mmol/L) C. 6.0 mg/dL (1.9 mmol/L) D. 6.5 mg/dL (2.1 mmol/L)

A. 4.0 mg/dL (1.3 mmol/L) The normal range of serum phosphate is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The only option that indicates improvement in the client's condition is the serum phosphate level of 4.0 mg/dL (1.3 mmol/L). The values in the remaining options represent elevated serum phosphate values.

A client with diabetes mellitus reports to the clinic for determination of the glycosylated hemoglobin (HbA1c) level. Which value on this laboratory test indicates client compliance with the prescribed diabetic regimen? A. 6% B. 2.8% C. 10% D. 15%

A. 6% The HbA1c measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Depending on health care provider preference, the level should be <6% for an adult without diabetes. Elevations in blood glucose will cause elevations in the amount of glycosylation. Elevations indicate continued need for teaching related to prevention of hyperglycemic episodes.

The nurse instructs a client with diabetes mellitus who takes insulin about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should inform the client that a blood glucose level of which value indicates hypoglycemia? A. 60 mg/dL (3.3 mmol/L) B. 90 mg/dL (5.0 mmol/L) C. 110 mg/dL (6.1 mmol/L) D. 120 mg/dL (6.7 mmol/L)

A. 60 mg/dL (3.3 mmol/L) The principal adverse effect of insulin therapy is hypoglycemia, a blood glucose level of 60 mg/dL (3.3 mmol/L) or lower. The remaining options identify values that are in the normal blood glucose range.

The nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse should expect the hematocrit level for this client to be noted at which level? A. 60% (0.60) B. 47% (0.47) C. 45% (0.45) D. 32% (0.32)

A. 60% (0.60) The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. Because hematocrit is measured as a proportion of red blood cells to a volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit level. In a client with dehydration, the nurse would expect to note that the hematocrit level is increased. Conversely, an increase in fluid can cause a decrease in the hematocrit level.

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client? A. Blood glucose level B. Serum calcium level C. Serum magnesium level D. Serum albumin concentration

A. Blood glucose level Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplantation, the client's serum electrolyte levels should be better regulated, although corticosteroids also could cause sodium retention and potassium depletion. The serum albumin, magnesium, and calcium will not be affected.

The nurse is caring for a client with Paget's disease who has a serum calcium level of 12.3 mg/dL (3.1 mmol/L). The nurse should check to see that which medication is available in the stock medication supply for possible use to reverse this elevation? A. Calcitonin B. Vitamin D C. Calcium chloride D. Calcium gluconate

A. Calcitonin The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that which level indicates the need for follow-up and immediate notification of the health care provider (HCP)? A. Calcium 4.0 mg/dL (1.0 mmol/L) B. Sodium 140 mEq/L (145 mmol/L) C. Potassium 4.0 mEq/L (4.0 mmol/L) D. Magnesium 2.0 mEq/L (1 mmol/L)

A. Calcium 4.0 mg/dL (1.0 mmol/L) The normal reference level for calcium is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). The reported level is low, requiring immediate notification of the HCP. The normal electrolyte levels for an adult client are sodium 135 to 145 mEq/L (135 to 145 mmol/L), potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L), and magnesium 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L).

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. A. Check the residual volume. B. Aspirate the stomach contents. C. Turn off the suction to the nasogastric tube. D. Remove the tube and place it in the other nostril. E. Test the stomach contents for a pH indicating acidity.

A. Check the residual volume. B. Aspirate the stomach contents. C. Turn off the suction to the nasogastric tube. E. Test the stomach contents for a pH indicating acidity. By aspirating stomach contents, the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition? A. Consistent with glomerulonephritis B. Inconsistent with glomerulonephritis C.Unclear; no conclusion can be drawn D.Indicative of impending acute kidney injury

A. Consistent with glomerulonephritis Gross hematuria and proteinuria are the classic signs of glomerulonephritis. The urine may be small in volume, dark or smoky from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal an elevated level of blood urea nitrogen, creatinine, C-reactive protein, and antistreptolysin O titer.

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply. A. Dehydration B. Catabolic state C. High-protein diet D. Fluid volume excess E. Obstructive uropathy F. Acute renal tubular acidosis

A. Dehydration B. Catabolic state C. High-protein diet E. Obstructive uropathy Causes of an increased BUN to creatinine ratio include dehydration, a catabolic state, a high-protein diet, and obstructive uropathy. A decreased ratio is caused by fluid volume excess or acute renal tubular acidosis.

A client is undergoing a 2-hour glucose tolerance test. The nurse assesses for which client factors that can interfere with the test period results? Select all that apply. A. Experiencing stress B. Fasting before the test period C. Voiding during the test period D. Eating a small snack or candy during the test period E. Having an episode of diarrhea before the test period F. Being unable to eat the entire test meal or vomiting some or all of the meal

A. Experiencing stress D. Eating a small snack or candy during the test period F. Being unable to eat the entire test meal or vomiting some or all of the meal Some interfering factors that can result in inaccurate test findings include experiencing stress, being unable to eat the entire test meal or vomiting during the test period, and eating a small snack or candy during the test period. Voiding during the test period, fasting for 4 hours before the test period, and having an episode of diarrhea before the test period would not interfere with the test results.

A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply. A. Glycosuria B. Albuminuria C. Dehydration D. Diabetes insipidus E. High creatinine level F. Increased blood urea nitrogen (BUN)

A. Glycosuria B. Albuminuria C. Dehydration Specific gravity evaluates the kidneys' ability to regulate fluid balance and the hydration status of the body. A specific gravity level of 1.034 is high. Some causes for high specific gravity levels are dehydration, albuminuria, and glycosuria. BUN and creatinine levels do not evaluate hydration status. Diabetes insipidus is related to low specific gravity levels.

The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions? A. Heart failure B. Addison's disease C. A severe burn injury D. Adrenal insufficiency

A. Heart failure The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A level of 150 mEq/L (150 mmol/L) would indicate hypernatremia. Hypernatremia is noted in such conditions as heart failure, Cushing's disease, dehydration, diabetes insipidus, diaphoresis, diarrhea, and hypovolemia. Hyponatremia would be noted in the conditions identified in the remaining options.

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply. A. Hold the finger in a dependent position during the test. B. Use gentle pressure to obtain an adequate amount of blood. C. Obtain the blood specimen by puncturing the central tip of the finger. D. Obtain the blood specimen by puncturing the lateral side of the finger. E. Allow the drop of blood to form without squeezing near the puncture site. F. Clean the site with an antiseptic swab, and then puncture the site immediately.

A. Hold the finger in a dependent position during the test. B. Use gentle pressure to obtain an adequate amount of blood. D. Obtain the blood specimen by puncturing the lateral side of the finger. When obtaining a droplet of blood for a blood glucose monitor, the site needs to be cleaned with an antiseptic swab and then allowed to dry completely. The puncture site should be the lateral side of the finger because the central tip contains more nerves and may be more painful. Holding the finger in a dependent position improves blood flow to the puncture site. Gentle pressure may be needed to obtain an adequate amount of blood for the test strip.

A client is receiving oral anticoagulant therapy with warfarin. The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse should anticipate which prescription to be prescribed for this client? A. Hold the next dose of warfarin. B. Increase the next dose of warfarin. C. Administer the next dose of warfarin. D. Stop the warfarin, and administer heparin.

A. Hold the next dose of warfarin. The normal PT is 11 to 12.5 seconds for adults. Appropriate therapy for full anticoagulation should prolong the PT by 1.5 to 2 times. Because the value stated is extremely high, the nurse should anticipate that the client would not receive further doses at this time. If the level were too high, the antidote (vitamin K) could also be prescribed. It would be dangerous to add a different anticoagulant to the client's regimen at this time, as in option 4.

The nurse is administering a cleansing enema to a client with fecal impaction. Before administering the enema, the nurse should place the client in which position? A. Left Sims' position B. Right Sims' position 3.On the left side of the body, with the head of the bed elevated 45 degrees 4.On the right side of the body, with the head of the bed elevated 45 degrees

A. Left Sims' position For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. A. Leukopenia B. Elevated hemoglobin C. Elevated liver enzymes D. Elevated serum bilirubin level E. Elevated blood urea nitrogen (BUN) F. Elevated serum erythrocyte sedimentation rate (ESR)

A. Leukopenia C. Elevated liver enzymes D. Elevated serum bilirubin level F. Elevated serum erythrocyte sedimentation rate (ESR) Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESRs. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

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. A. Platelets 35,000 mm3 (35 × 109/L) B. Sodium 150 mEq/L (150 mmol/L) C. Potassium 5.0 mEq/L (5.0 mmol/L) D. Segmented neutrophils 40% (0.40) E. Serum creatinine, 1 mg/dL (88.3 mmol/L) F. White blood cells, 3000 mm3 (3.0 × 109/L)

A. Platelets 35,000 mm3 (35 × 109/L) B. Sodium 150 mEq/L (150 mmol/L) D. Segmented neutrophils 40% (0.40) F. White blood cells, 3000 mm3 (3.0 × 109/L) The normal values include the following: platelets 150,000-400,000 mm3 (150-400 × 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 mmol/L); and white blood cells 5000-10,000 mm3 (5.0-10.0 × 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.

The clinic nurse has obtained a throat culture specimen from a client in whom a throat infection is suspected. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short staffed and the laboratory assistant will pick up the specimen in 2 hours. Which is the appropriate nursing action? A. Refrigerate the specimen. B. Tell the client to return in 1 hour for a repeat throat culture. C. Contact the health care provider (HCP) who prescribed the specimen. D. Tell the laboratory that someone needs to pick up the specimen immediately.

A. Refrigerate the specimen. A specimen for a culture should not be allowed to sit unrefrigerated for longer than 1 hour because the unrefrigerated temperature can affect the results of the testing. It is not appropriate to request that the client return for a repeat culture, and it is inappropriate to demand that the laboratory pick up the specimen immediately. There is no reason to contact the HCP.

The nurse is admitting a client who has a cough, dyspnea, and abnormal chest x-ray who is otherwise healthy. The client has an elevated serum angiotensin-converting enzyme (SACE) level. Based on this result, what condition is the client at risk for? A. Sarcoidosis B. Pulmonary fibrosis C. Bacterial pneumonia D. Chronic obstructive pulmonary disease (COPD)

A. Sarcoidosis SACE is found in pulmonary epithelial tissue and is used in the detection of sarcoidosis. It does not diagnose pulmonary fibrosis, bacterial pneumonia, or COPD. Normal SACE levels are 8 to 53 U/L. Elevated SACE levels are found in a high percentage of clients with sarcoidosis (an autoimmune granulomatous disease that affects many organs, especially the lungs). It is also used to monitor the clinical course of the disease.

The nurse has been giving a client furosemide intravenously for an exacerbation of heart failure. The nurse monitors what potential abnormal blood levels that frequently occur when this medication is administered? Select all that apply. A. Serum sodium B. Serum protein C. Serum albumin D. Serum potassium E. Serum creatinine

A. Serum sodium D. Serum potassium Serum sodium, potassium, and chloride levels can be affected with the administration of furosemide. Furosemide is a loop diuretic, and these medications block the Na-K-Cl2 (sodium, potassium, chloride cotransporter 2 [NKCC2]) in the nephron on the ascending limb of the loop of Henle, where most sodium is reabsorbed. Serum protein, albumin, and creatinine levels are not affected with the administration of this medication.

The nurse is reviewing the laboratory results of estimated glomerular filtration rate (eGFR). What are some conditions that can cause a decreased eGFR? Select all that apply. A. Shock B. Cystitis C.Dehydration D. Fluid overload E. Heart failure (HF) F. Cirrhosis with ascites

A. Shock C. Dehydration E. Heart failure (HF) F. Cirrhosis with ascites eGFR is an equation that uses the serum creatinine, age, and numbers that vary depending on sex and ethnicity to calculate the eGFR with very good accuracy. The value may be inaccurate in extremes of age; in clients with severe malnutrition or obesity, paraplegia, or quadriplegia; and in pregnant women. The eGFR can also be used to calculate medication dosage in clients with decreased renal function. Conditions causing decreased eGFR are shock, dehydration, HF, and cirrhosis with ascites. Decreased eGFR is not related to cystitis or fluid overload. Conditions that are associated with decreased blood flow to the kidney will decrease eGFR. Shock, dehydration, HF, and cirrhosis with ascites can lead to impaired kidney function related to renal artery atherosclerosis, glomerulonephritis, and acute tubular necrosis.

A child is receiving edetate calcium disodium (calcium ethylenediaminetetraacetic acid [EDTA]) by intravenous (IV) infusion for the treatment of lead poisoning. The health care provider (HCP) prescribes a blood level lead concentration measurement. Which action should the nurse take to obtain the blood specimen? A. Stop the IV infusion for 1 hour before obtaining the blood. B. Irrigate the IV line with normal saline before drawing the blood. C. Obtain the blood specimen on the extremity that is not receiving the IV infusion. D. Maintain the client on NPO (nothing by mouth) status 12 hours before obtaining the blood specimen.

A. Stop the IV infusion for 1 hour before obtaining the blood. If the child is receiving an IV infusion of calcium EDTA, the infusion should be stopped for 1 hour before a blood level lead concentration is obtained. Otherwise, the blood level lead concentration will indicate a falsely elevated reading. Therefore, the actions in the remaining options are incorrect.

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding? A. Red blood cells (negative) B. Protein 100 mg/dL (1 g/L) C. Glucose 52 mg/dL (2.9 mmol/L) D. White blood cells 3 cells/mcL (3 × 106/L)

B. Protein 100 mg/dL (1 g/L) Protein (15 to 45 mg/dL [0.15 to 0.45 g/L]) and glucose (50 to 75 mg/dL [2.8 to 4.2 mmol/L]) normally are present in CSF; however, the protein level for this client is above the expected range. The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 5 cells/mcL [0 to 5 × 106/L]).

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review? A. Hemoglobin (Hgb) B. Prothrombin time (PT) C. Red blood cell (RBC) level D. Partial thromboplastin time (PTT)

B. Prothrombin time (PT) PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy. While heparin and warfarin are both anticoagulants, they both work differently in the body. ... A PT/INR (prothrombin time and international normalized ratio) is done when taking warfarin to determine clotting time of your blood. Heparin acts quickly and is used in more emergent situations.

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? A. 56% (0.56) B. 48% (0.48) C. 37% (0.38) D. 34% (0.34)

B. 48% (0.48) The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? A. The client needs to have the test repeated. B. Client results are within the therapeutic range. C. Client results are higher than the therapeutic range. D. Client results are lower than the needed therapeutic level.

B. Client results are within the therapeutic range. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range.

The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with a diagnosis of meningitis. Which laboratory findings are expected to be noted with bacterial meningitis? Select all that apply. A. Increased glucose level B. Elevated protein level C.Increased white blood cells (WBCs) D. Clear appearance of the cerebrospinal fluid (CSF) E. Elevated cerebrospinal fluid pressure

B. Elevated protein level C.Increased white blood cells (WBCs) E. Elevated cerebrospinal fluid pressure If a bacterial infection of CSF is present, findings include reduced glucose level, an elevated protein level, increased WBCs, a cloudy appearance of CSF, and an elevated CSF pressure.

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

B. Holding the next dose of warfarin 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.

The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this client? A. Normal B. Increased C. Decreased D. Insignificant

B. Increased The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentage of platelet aggregation. Increased platelet aggregation may occur after surgery or with acute illness, venous thrombosis, and pulmonary embolism.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition? A. Anemia B. Infection C. Bleeding D. Dehydration

B. Infection Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.

The nurse is collecting a 24-hour composite urine specimen. Besides electrolytes and glucose, what other components are measured? Select all that apply. A. Blood B. Protein C. Minerals D. Creatinine E. 17-ketosteroids F. Catecholamines

B. Protein C. Minerals D. Creatinine E. 17-ketosteroids F. Catecholamines Composite urine collection measures specific components, such as electrolytes, glucose, protein, 17-ketosteroids, catecholamines, creatinine, and minerals. Twenty-four-hour specimens do not measure blood. Composite specimens are collected over a period ranging from 2 to 24 hours.

A client with a diagnosis of question of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply. A. Cardiac enzymes B. Rheumatic factor C. Fasting blood glucose D. Antinuclear antibody (ANA) E. Erythrocyte sedimentation rate (ESR) F. Anticyclic citrullinated peptide antibody (anti-CCP)

B. Rheumatic factor D. Antinuclear antibody (ANA) E. Erythrocyte sedimentation rate (ESR) F. Anticyclic citrullinated peptide antibody (anti-CCP) Blood tests commonly used to confirm the diagnosis of RA include ANA, rheumatic factor, ESR, and anti-CCP. Cardiac enzymes and fasting blood glucose tests are not used to diagnose this condition. ANA is used to diagnose autoimmune diseases. An elevated ESR is used to detect inflammation of joints associated with RA. Rheumatoid factor is useful in the diagnosis of RA. Anti-CCP appears early in the course of RA and is present in the blood of most clients with the disease.

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? A. Taking a rectal temperature for a client who has undergone nasal surgery B. Taking an oral temperature for a client with a cough and nasal congestion C. Taking an axillary temperature for a client who has just consumed hot coffee D. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic

B. Taking an oral temperature for a client with a cough and nasal congestion 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 measure the temperature on the neck behind the ear, avoiding the forehead.

The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem? A. Anemia B. Bleeding C.Infection D. Dehydration

C.Infection Neutrophils arise from stem cells and complete the maturation process in the bone marrow. They belong to a class of leukocytes known as granulocytes because of the large number of granules present inside each cell. Neutrophils provide the first internal line of defense, via phagocytosis, against foreign invaders (especially bacteria) in blood and extracellular fluid. If the neutrophil count is low, the client is at risk for infection. The remaining options are not associated with the function of neutrophils.

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis? A. Leukemia B. Hemolytic anemia C. Pernicious anemia D. Iron deficiency anemia

C. Pernicious anemia The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. The hematocrit level measures the percentage of red blood cells in whole blood. Elevated hematocrit levels are seen in persons with dehydration, pernicious anemia, or polycythemia. Therefore, the conditions in the remaining options are incorrect.

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. Mark the tube at 10 inches (25.5 cm). B. Mark the tube at 32 inches (81 cm). C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches (56 to 66 cm). The remaining options identify incorrect procedures for measuring the length of the tube.

The nurse is monitoring for agranulocytosis in a client who is taking clozapine. The nurse should check which serum laboratory result to determine the presence of agranulocytosis? A. Basophil count lower than normal B. Creatinine level greater than normal C. White blood cell (WBC) count lower than normal D. Blood urea nitrogen (BUN) level greater than normal

C. White blood cell (WBC) count lower than normal In agranulocytosis, the WBC count decreases as a result of bone marrow suppression, and the deficiency causes the affected client to become susceptible to infection. Because some antipsychotic medications, such as clozapine, can produce this adverse effect, a baseline WBC count is obtained and is evaluated periodically during therapy with this medication. Although a basophil count is a component of the WBC differential count, it does not provide adequate data to determine the presence of agranulocytosis. Levels of BUN and creatinine that are higher than normal may indicate renal disease. Agranulocytosis is a condition where the absolute neutrophil count is less than 100 per microliter of blood. It can be serious and even life-threatening. Untreated, it can lead to death from the blood infection called septicemia.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse notes that the red blood cell (RBC) count is increased. The nurse interprets that this finding may be related to which condition or treatment? A. Iron deficiency B. Vitamin deficiency C. Corticosteroid therapy D. Bone marrow depression

C. Corticosteroid therapy Increased RBCs are seen with decreased cardiac output, impaired pulmonary gas exchange, corticosteroid therapy, polycythemia vera, severe diarrhea, and dehydration. The conditions in the remaining options are not associated with an increased RBC count.

The nurse is caring for a client with a diagnosis of fluid volume overload. The nurse reviews the laboratory test results and would expect to note which finding about the hematocrit level? A. Normal B. Increased C. Decreased D. Insignificant related to the condition

C. Decreased Because the hematocrit is measured as a proportion of red blood cells to the volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit levels. Conversely, an increase in fluids can cause a decrease in the hematocrit level. A client with a diagnosis of fluid volume overload would have a decreased hematocrit level.

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? A. Normal B. Increased C. Decreased D. Insignificant

C. Decreased The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease. Idiopathic thrombocytopenic purpura is an immune disorder in which the blood doesn't clot normally. This condition is now more commonly referred to as immune thrombocytopenia (ITP). ITP can cause excessive bruising and bleeding. An unusually low level of platelets, or thrombocytes, in the blood results in ITP.

The nurse receives a telephone laboratory report indicating that a diabetic client has a glycosylated hemoglobin (HgbA1c) level of 7.6%. In which priority area should the nurse plan to provide diabetic teaching? A. Avoidance of infection B. Rotation of insulin injection sites C. Measures to prevent hyperglycemia D. Avoidance of hypoglycemic episodes

C. Measures to prevent hyperglycemia The normal level for HgbA1c is <6% in an adult without diabetes. Regardless, a level of 7.6% is elevated. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes because the results are reflective of the blood glucose levels over the preceding 2- to 3-month period.

The evening shift nurse is reviewing the laboratory results of a client's urine culture showing 100,000 bacterial units/mL of urine. What should be the nurse's action? A. Notify the HCP during rounds in the morning. B. No action is needed because this is normal value. C. Page the health care provider (HCP) with the results. D. Collect another urine specimen to confirm the results.

C. Page the health care provider (HCP) with the results. The HCP needs to be notified. A colony count of 100,000 is considered a positive culture and could be indicative of pyelonephritis if accompanied by fever and flank pain. A positive culture that is accompanied by dysuria, frequency, and urgency is indicative of cystitis. The other options are not correct and delay necessary intervention.

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one? A. Sepsis B. Pneumonia C. Pernicious anemia D. Coronary artery disease

C. Pernicious anemia A differential WBC count is the leukocyte count broken down (differentiated) according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown. The conditions in the remaining options are not associated with this finding.

The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made? A. "It can detect heart disease in my baby." B. "It will discover the presence of cancer in my baby." C. "It will check for the presence of a genetic condition in my infant." D. "It will allow me to institute measures to prevent complications if the level is elevated."

D. "It will allow me to institute measures to prevent complications if the level is elevated." Phenylketonuria is a genetic disorder that is characterized by an inability of the body to use the essential amino acid phenylalanine. The phenylalanine level is checked to screen for this disorder. Newborn screening tests are mandatory in all 50 states and are most reliable if the blood sample is taken after the infant has ingested a source of protein. The objective in diagnosing or treating phenylketonuria is to prevent cognitive impairment. Minimal or absent phenylalanine hydroxylase activity results in profound cognitive impairment if not treated early with dietary restriction of phenylalanine. The phenylketonuria test is not used to detect cardiac disease, discover the presence of cancer, or check for the presence of a genetic condition.

The nurse is evaluating the laboratory test results for a client with diabetes mellitus seen in the health care clinic. The nurse determines that which glycosylated hemoglobin level value shows poor adherence to therapy? A. 6% B. 2.7% C. 7.5% D. 10%

D. 10% The normal glycosylated hemoglobin in an adult without diabetes is <6%. Levels >8% indicate poor diabetic control and need for adherence to regimen or changes in therapy. The results in the remaining options indicate adequate control.

After completing an assessment and reviewing the laboratory test results of a client admitted to the hospital with acute abdominal pain, the nurse should take action for which noted serum amylase level? A. 60 Somogyi units/dL (27 U/L) B. 100 Somogyi units/dL (50 U/L) C. 120 Somogyi units/dL (60 U/L) D. 200 Somogyi units/dL (100 U/L)

D. 200 Somogyi units/dL (100 U/L) The normal serum amylase level ranges from 60 to 120 Somogyi units/dL (30 to 220 U/L), depending on the laboratory running the test. Option 4 is out of range for a serum amylase level and would require action by the nurse. The values in the remaining options are normal serum amylase levels and would not require any action.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? A. Checking for normal serum electrolyte levels B. Checking for normal pH of the gastric aspirate C. Checking for proper nasogastric tube placement D. Checking for the presence of bowel sounds in all 4 quadrants

D. Checking for the presence of bowel sounds in all 4 quadrants Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube.

The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition? A. Diarrhea B. Dehydration C. Multiple myeloma D. Cirrhosis of the liver

D. Cirrhosis of the liver The normal albumin level ranges from 3.5 to 5 g/dL (35 to 50 g/L). The albumin level is decreased in many conditions, such as acute infection, ascites, alcoholism, burns, and cirrhosis. The remaining options identify conditions in which the albumin level is increased. Albumin is a protein made by your liver. Albumin helps keep fluid in your bloodstream so it doesn't leak into other tissues. It is also carries various substances throughout your body, including hormones, vitamins, and enzymes. Low albumin levels can indicate a problem with your liver or kidneys. When your kidneys start to fail, albumin starts to leak into your urine. This causes a low albumin level in your blood. Albumin carries substances such as hormones, medicines, and enzymes throughout your body.

The long-term care nurse about to give a daily dose of digoxin is told that a serum digoxin level drawn earlier in the day measured 1.4 ng/mL (1.7 nmol/L). Which action should the nurse take first? A. Administer the daily dose of the medication. B. Report the finding to the health care provider (HCP). C. Record the normal value on the intershift report sheet. D. Gather data from the client related to signs of toxicity.

D. Gather data from the client related to signs of toxicity. The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A value of 1.4 ng/mL (1.7 nmol/L) exceeds the therapeutic range and could be toxic to the client. The nurse should gather data about signs of digoxin toxicity first and then notify the HCP. Option 1 is incorrect because the next dose should not be administered automatically. Recording the value on the intershift report sheet is incorrect because the value is high, not normal, and dismisses the subject at hand.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition? A. Dehydration B. Pernicious anemia C.Polycythemia vera D. Iron deficiency anemia

D. Iron deficiency anemia A hematocrit of 30% (0.30) or less indicates iron deficiency anemia. Decreased values occur in leukemia, acute hemorrhage, iron deficiency anemia, and hemolytic anemia. The conditions in the remaining options represent conditions in which an elevated hematocrit would be noted.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? A. Insert the tube quickly. B. Notify the health care provider immediately. C. Remove the tube and reinsert it when the respiratory distress subsides. D. Pull back on the tube and wait until the respiratory distress subsides.

D. Pull back on the tube and wait until the respiratory distress subsides. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.