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A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.
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The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?
- A. Skin turgor
- B. Dry mucous membranes
- C. Elevated temperature
- D. Increased pulse pressure
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.
A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?
- A. Peanut butter and jelly with enriched bread
- B. Baked potato with sour cream
- C. Bagel with cream cheese
- D. Fruit salad and carrot sticks
Correct Answer: A
Rationale: Peanut butter and enriched bread provide complementary proteins, which are important for a vegetarian diet. Peanut butter is a good source of protein and when paired with enriched bread, it forms a complete protein source. Choice B, baked potato with sour cream, lacks complete protein. Choice C, bagel with cream cheese, also does not provide a complete protein source. Choice D, fruit salad and carrot sticks, do not contain sufficient protein to serve as a main protein source for a vegetarian diet.
When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified to have botulism
- B. A toddler who ate a number of ibuprofen tablets
- C. A preschooler who swallowed powdered plant food
- D. A school-aged child who took a handful of vitamins
Correct Answer: A
Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.
After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?
- A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?
- A. Nausea and vomiting
- B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. Diffuse macular rash
- D. Muscle tenderness
Correct Answer: B
Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.