Nokea
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
- A. Measure the client's pulse and blood pressure
- B. A 5-year-old who is cognitively impaired
- C. Applying oxygen by mask or nasal cannula
- D. Increase oral fluid intake
Correct Answer: D
Rationale: For a client with dehydration-induced confusion, the priority is to address the dehydration by increasing fluid intake to restore hydration status, which may help resolve confusion. Measuring vital signs, assessing cognitive status, or applying oxygen may be secondary actions but do not directly address the underlying cause of dehydration.
You may also like to solve these questions
Which meal choice is most appropriate for a client on a low-sodium diet?
- A. Ham sandwich with mustard
- B. Tomato soup with crackers
- C. Spaghetti with meat sauce
- D. Grilled chicken breast with glazed carrots
Correct Answer: D
Rationale: Clients on restricted sodium diets should avoid processed, smoked, and pickled foods and those with sauces and condiments. Foods lowest in sodium include fish, poultry, and fresh produce. Grilled chicken breast with glazed carrots is the lowest in sodium.
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, whole-wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct Answer: C
Rationale: Meat, dairy products, and dried fruit have high concentrations of potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of high-potassium items.
A nurse evaluates a client who is being treated for hypokalemia. Which findings indicate that treatment is effective? (Select all that apply.)
- A. Respiratory rate of 8 breaths/min
- B. Strong, productive cough
- C. Absent deep tendon reflexes
- D. Active bowel sounds
- E. U waves present on the ECG
Correct Answer: B,D
Rationale: A strong, productive cough indicates improved muscle strength, and active bowel sounds suggest resolution of hypokalemia-related gastrointestinal issues.
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme; [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
- A. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
- B. Daily weight increase from 55 kg to 57 kg
- C. Heart rate decrease from 100 beats/min to 80 beats/min
- D. Respiratory rate increase from 12 breaths/min to 15 breaths/min
Correct Answer: A
Rationale: ACE inhibitors will disrupt the renin-angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client's blood pressure.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Bowel sounds
- B. Depth of respirations
- C. Grip strength
- D. Electrocardiography
Correct Answer: B
Rationale: A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient.