The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin is 2.8 mg/dL. The nurse would anticipate which finding in the patient's urine?
a. Dark color
b. Low specific gravity
c. Very scant amount
d. Foul odor
A
Normal serum bilirubin is 0.1 to 1.2 mg/dL. Jaundice is present at readings above 2.5 mg/dL. The patient who is jaundiced will have dark, tea-colored urine. Specific gravity refers to the concentration of the urine. The amount and odor of urine will not be directly influenced by the bilirubin level.
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The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding? (Select all that apply.)
a. The patient's urinary output increased to 40 mL/hr. b. The patient's pulse has risen from 76 to 112 beats/min. c. The patient states that his abdominal pain is worse than yesterday. d. The patient complains of generalized itching. e. The patient's hematocrit dropped from 14.6 to 11.0 g/dL f. The patient has not been able to have a bowel movement since before surgery.
The new mother calls the nurse to her room to show how her baby is "jerking around" when she changes his position. The nurse explains that this response is the normal:
a. traction reflex. b. Babinski reflex. c. tonic neck reflex. d. Moro reflex.
A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate?
a. Document findings on the client's chart and inform the physician. b. Perform additional assessments for post-traumatic stress disorder. c. Educate the client on nonpharmaceutical methods to promote sleep. d. Plan to initiate a referral to a psychologist experienced in survivor issues.
The nurse is coordinating care for a newly admitted older adult. The patient is diagnosed with hypertension, asthma, atrial fibrillation, mild osteoarthritis, and glaucom
a. Before administering the patient's corticosteroid medication, the nurse is especially interested in which of the follow-ing? (Select all that apply.) a. The name of the patient's hypertension medication b. What the patient uses to manage arthritic pain c. Whether the patient feels the asthma is well controlled d. Whether the patient takes low-dose aspi-rin regularly e. Whether the patient has ever had glauco-ma-related surgery