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A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
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A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
- A. Encourage frequent visits from friends.
- B. Apply restraints to the upper extremities.
- C. Play soft, soothing music.
- D. Keep the over-the-bed light on.
Correct Answer: C
Rationale: The correct answer is C: Play soft, soothing music. This is beneficial for the older adult with dementia post-surgery as music has been shown to reduce anxiety, improve mood, and promote relaxation. It can also help in reducing agitation and promoting better sleep. Encouraging frequent visits from friends (A) may overwhelm the client. Applying restraints to the upper extremities (B) can lead to increased agitation and discomfort. Keeping the over-the-bed light on (D) may disrupt sleep patterns and worsen confusion.
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
- A. A client who has peritonitis reports generalized abdominal pain.
- B. A client who has angina reports substernal chest pain.
- C. A client who is postoperative reports incisional pain.
- D. A client who has pancreatitis reports pain in the left shoulder.
Correct Answer: D
Rationale: Referred pain is pain perceived at a site different from its point of origin. In the case of pancreatitis, pain is often referred to the left shoulder due to shared nerve pathways. The other choices involve pain directly related to the affected area (peritonitis, angina, postoperative incision), making them incorrect.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.