Nokea
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Monitor vital signs every two (2) hours until stable.
- B. Monitor the client’s oral intake and urinary output daily.
- C. Administer mouth care when bathing the client.
- D. Weigh the client weekly in the same clothing at the same time.
- E. Assess skin turgor and mucous membranes every shift.
Correct Answer: A,B,E
Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.
You may also like to solve these questions
Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment?
- A. Pulse rate
- B. Body weight
- C. A Abdominal girth
- D. Urine output
Correct Answer: B
Rationale: Body weight is the most valuable assessment, as weight loss after dialysis indicates effective removal of excess fluid.
When the nurse reviews the client's medical history, which finding most likely precipitated the present illness?
- A. A recent streptococcal throat infection
- B. A recent influenza infection
- C. A recent episode of gastroenteritis
- D. A recent urinary tract infection
Correct Answer: A
Rationale: A recent streptococcal throat infection is a common trigger for acute glomerulonephritis due to immune-mediated kidney damage.
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
The nurse identifies the concepts of elimination and immunity for a female client diagnosing with a urinary tract infection. Which discharge instructions should the nurse provide the client? Select all that apply.
- A. Teach the client to wipe from front to back after voiding.
- B. Encourage the client to drink cranberry juice each morning.
- C. Inform the client that frequent episodes of incontinence are expected.
- D. Discuss the signs and symptoms of a recurrent infection.
- E. Have the client fill a container of water to sip until at least 2,000 mL is consumed.
- F. Request that the client sit in a tub of warm water twice a day for 25 minutes.
Correct Answer: A,B,D,E
Rationale: Wiping front to back prevents bacterial spread, cranberry juice may reduce UTI risk, discussing recurrent symptoms aids early detection, and 2,000 mL fluid intake flushes the bladder. Incontinence is not expected, and tub baths increase infection risk.
It is most appropriate for the nurse to advise the client that taking this medication will have which effect on the urine?
- A. The urine will look cloudy.
- B. The urine will appear orange.
- C. The urine will become scant.
- D. The urine will have a strong odor.
Correct Answer: B
Rationale: Phenazopyridine (Pyridium) commonly causes the urine to turn orange, which is a harmless side effect that the client should be informed about.