A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Respiratory rate and depth

Rectal temperature

Blood pressure lying, sitting and standing

Pulse oximetry reading at rest

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best answer. Respiratory rate and depth can indicate the client's oxygenation and ventilation, but not necessarily their fluid status. The client may have normal or increased respiratory rate and depth due to dehydration, acidosis, or anxiety, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's respiratory rate and depth, but also assess other parameters of fluid status.

Choice B reason: This is not the best answer. Rectal temperature can indicate the client's core body temperature, but not necessarily their fluid status. The client may have normal or elevated rectal temperature due to infection, inflammation, or dehydration, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's rectal temperature, but also assess other parameters of fluid status.

Choice C reason: This is the best answer. Blood pressure lying, sitting and standing can indicate the client's fluid status and vascular tone. The client may have low blood pressure due to fluid loss, hypovolemia, or vasodilation, and this can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. The nurse should measure the client's blood pressure in different positions and observe for signs of orthostatic hypotension, such as dizziness, fainting, or blurred vision.

Choice D reason: This is not the best answer. Pulse oximetry reading at rest can indicate the client's oxygen saturation, but not necessarily their fluid status. The client may have normal or decreased pulse oximetry reading due to hypoxia, anemia, or poor peripheral perfusion, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's pulse oximetry reading, but also assess other parameters of fluid status.

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Correct Answer is B

Explanation

Choice A reason: It is not the best intervention to exclude the family from the exercise program. Family involvement can provide support, motivation, and accountability for the client. Family members can also participate in the exercise program and benefit from its positive effects on blood pressure and overall health.

Choice B reason: This is the best intervention to help the client maintain the exercise program. Adapting the program to the client's needs and abilities ensures that the exercise is appropriate, safe, and effective for the client. It also increases the client's confidence, satisfaction, and adherence to the program.

Choice C reason: Providing the client with specific details of how to perform the exercises is an important intervention, but not the best one. The client may still have difficulties or barriers to maintaining the exercise program, such as lack of time, resources, or motivation. The nurse should also assess the client's readiness, preferences, and goals for the exercise program.

Choice D reason: Reassuring the client that they will be able to do the exercise program is a supportive intervention, but not the best one. The client may not feel reassured if the exercise program is too challenging, unrealistic, or unappealing for them. The nurse should also monitor the client's progress, feedback, and outcomes of the exercise program.

A. Do you ever use oxygen? B. How many pillows do you sleep on? C. Do you feel rested after sleeping? D. How far can you walk before feeling short of breath?

Correct Answer is A

Explanation

Choice A reason: The nurse would include the question of whether the client ever uses oxygen, as this can be related to erythema. Erythema is a condition where the skin becomes red and inflamed due to increased blood flow or irritation. ¹ One possible cause of erythema is oxygen toxicity, which is a condition where the lungs and tissues are damaged by exposure to high levels of oxygen. ² The nurse would ask the client if they ever use oxygen, especially at high concentrations or for long periods of time, as this can increase the risk of oxygen toxicity and erythema.

Choice B reason: The nurse would not include the question of how many pillows the client sleeps on, as this is not related to erythema. The number of pillows the client sleeps on may indicate the presence of other conditions, such as sleep apnea, acid reflux, or heart failure, but not erythema. ³ The nurse would ask the client about their sleeping habits and preferences, but not specifically about the number of pillows they use.

Choice C reason: The nurse would not include the question of whether the client feels rested after sleeping, as this is not related to erythema. The feeling of restfulness after sleeping may indicate the quality and quantity of sleep the client gets, which can affect their overall health and well-being, but not erythema. The nurse would ask the client about their sleep patterns and problems, but not specifically about their feeling of restfulness.

Choice D reason: The nurse would not include the question of how far the client can walk before feeling short of breath, as this is not related to erythema. The distance the client can walk before feeling short of breath may indicate the level of physical activity and fitness the client has, which can affect their cardiovascular and respiratory health, but not erythema. The nurse would ask the client about their exercise habits and limitations, but not specifically about their walking distance.

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A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working collaboratively with the physical therapist to develop an exercise program for a client recently diagnosed with hypertension. Which intervention would be best to assist the client in maintaining the exercise program?

Correct Answer is B

Explanation

In conducting a health history for a client with erythema, the nurse would include which question?

Correct Answer is A

Explanation

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