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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to high Fowler's.
- B. Request NPO status for the client.
- C. Check the client's respiratory rate and lung sounds.
- D. Measure the client's temperature.
Correct Answer: C
Rationale: A rapid infusion of IV fluid can cause fluid overload, leading to respiratory distress. Checking respiratory status helps assess for complications.
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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.
A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. A client who has NPO status since midnight for an endoscopy
- B. A client who has heart failure and is receiving diuretic therapy
- C. A client who has end-stage kidney disease who will undergo dialysis
- D. A client who has gastroenteritis and is receiving oral fluids
Correct Answer: B
Rationale: The correct answer is B: A client who has heart failure and is receiving diuretic therapy. In heart failure, the heart's ability to pump blood effectively is compromised, leading to fluid retention. Diuretics are prescribed to reduce fluid overload by increasing urine output. This process can potentially lead to fluid volume deficit if excessive fluid is removed. Clients with heart failure on diuretics are at risk for electrolyte imbalances and dehydration.
A: NPO status for an endoscopy does not necessarily indicate fluid volume deficit.
C: Clients with end-stage kidney disease undergoing dialysis are at risk for fluid volume overload due to the accumulation of waste products and fluid in the body.
D: Clients with gastroenteritis receiving oral fluids are typically at risk for fluid volume deficit, but the scenario does not provide enough information to confirm this as the correct choice.
In summary, choice B is correct because clients with heart failure on diuretics are at risk for fluid volume deficit due to the medication
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.
A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?
- A. At the beginning of the collection time, urinate and then discard the urine.
- B. Keep the collection container at room temperature.
- C. Save each urine collection in a separate container.
- D. At the end of the collection time, urinate and save the urine in a separate container.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Urinating and discarding the first urine sample helps ensure that the 24-hour collection period begins accurately. This initial voiding clears out any urine that has been in the bladder prior to the start of the collection. This step is crucial to obtain an accurate measurement of substances excreted over the 24-hour period.
Summary:
B: Keeping the collection container at room temperature is not crucial for accurate urine collection.
C: Saving each urine collection in a separate container may lead to inaccuracies in the final analysis.
D: Urinating and saving the final urine sample separately at the end of the collection period may skew the results.