A nurse evaluates the following data in a client's chart:
Admission Note
Laboratory Results
Wound Care Note
66-year-old male with a health history of a cerebral vascular accident and left-side paralysis
White blood cell count: 8000/mm3
Prealbumin: 15.2 mg/dL
Albumin: 4.2 mg/dL
Lymphocyte count: 2000/mm3
Sacral ulcer - 4 cm × 2 cm × 1.5 cm
Based on this information, which action should the nurse take?
a.
Perform a neuromuscular assessment.
b.
Request a dietary consult.
c.
Initiate Contact Precautions.
d.
Assess the client's vital signs.
ANS: B
The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided.
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