Nokea
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
- A. Bradycardia
- B. Hypotension
- C. Fever
- D. Poor skin turgor
- E. Peripheral edema
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (B) due to decreased blood volume, fever (C) as a result of dehydration and infection, and poor skin turgor (D) due to decreased tissue hydration. Bradycardia (A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
You may also like to solve these questions
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
- A. Presence of associated symptoms
- B. Location of the pain
- C. Pain quality
- D. Aggravating & relieving factors
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.
A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
- A. Extremes in age
- B. Impaired circulation
- C. Impaired/suppressed immune system
- D. Malnutrition
- E. Poor wound care
Correct Answer: B, C
Rationale: The correct answers are B (Impaired circulation) and C (Impaired/suppressed immune system). Impaired circulation can lead to decreased oxygen and nutrient delivery to the wound site, hindering the healing process. In this case, the adolescent may have impaired circulation due to diabetes mellitus. An impaired/suppressed immune system can also delay wound healing by impairing the body's ability to fight off infection and promote tissue repair. The other options are not applicable in this scenario: A (Extremes in age) does not apply as the client is an adolescent; D (Malnutrition) is not indicated as the client is tolerating a regular diet; and E (Poor wound care) is not evident as the incision is well-approximated and free of redness, with only scant serous drainage.