Nokea
A client who is receiving diuretic therapy comes to the clinic for a follow-up visit. The client states that his mouth is often dry and that he is 'urinating like there is no tomorrow.' Assessment reveals dry mucous membranes and decreased skin turgor. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Injury
- B. Risk for Deficient Fluid Volume
- C. Impaired Urinary Elimination
- D. Deficient Knowledge
Correct Answer: B
Rationale: Based on the client's report and assessment findings, a nursing diagnosis of Risk for Deficient Fluid Volume would be most appropriate.
You may also like to solve these questions
A nurse is assessing a client after administering a diuretic. Which of the following would lead the nurse to suspect that the client is experiencing a fluid and electrolyte imbalance? Select all that apply.
- A. Dry mouth
- B. Diaphoresis
- C. Muscle cramps
- D. Hypertension
- E. Tachycardia
Correct Answer: A,C,E
Rationale: Warning signs of a fluid and electrolyte imbalance include dry mouth, thirst, lethargy, weakness, drowsiness, restlessness, muscle pain or cramps, confusion, GI disturbances, hypotension, oliguria, tachycardia, and seizures.
A physician has prescribed bumetanide for a client with high blood pressure who also has renal insufficiency. Which of the following instructions should the nurse include in the teaching plan for this client?
- A. Avoid salt substitutes containing potassium
- B. Avoid over-the-counter drugs for cold symptoms
- C. Always take the drug before meals
- D. Omit the drug dose when feeling dizzy
Correct Answer: B
Rationale: The nurse should instruct the hypertensive client to avoid medications that increase blood pressure, such as OTC drugs for appetite suppression and cold symptoms.
A nurse suspects that a client who is receiving acetazolamide is developing hyponatremia based on assessment of which of the following? Select all that apply.
- A. Bradycardia
- B. Anorexia
- C. Hypotension
- D. Hypoglycemia
- E. Decreased skin turgor
Correct Answer: C,E
Rationale: The following are signs of hyponatremia: cold, clammy skin; decreased skin turgor; confusion; hypotension; irritability; and tachycardia.
A nurse is caring for a client with increased intraocular pressure who is receiving urea. After administering the drug, the nurse would assess the client for which of the following?
- A. Syncope
- B. Cramping
- C. Photosensitivity
- D. Blurred vision
Correct Answer: A
Rationale: The nurse should observe the client for syncope after administering urea.
A nurse is caring for a client with edema. The physician has prescribed diuretic therapy for the client. Which of the following would be most appropriate for the nurse to do?
- A. Ask the client to decrease fluid intake
- B. Gradually increase the drug dosage
- C. Administer the drug early in the day
- D. Encourage the client to exercise
Correct Answer: C
Rationale: The nurse should administer the drug early in the day to prevent any nighttime sleep disturbance caused by increased urination.