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 D

Explanation

Choice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

A. I will call dietary to bring you breakfast. B. Food may interact with the dye that is used for the test. C. I will ask the health care provider if the test can be rescheduled. D. The procedure is usually completed on an empty stomach.

Correct Answer is D

Explanation

Choice A reason: I will call dietary to bring you breakfast is not the best response by the nurse. This response may imply that the nurse is willing to compromise the test results or the client's safety by allowing them to eat before the test. The nurse should explain the rationale for fasting and offer the client some water or ice chips if allowed.

Choice B reason: Food may interact with the dye that is used for the test is not the best response by the nurse. This response may be partially true, but it is not specific or clear enough to justify the need for fasting. The nurse should explain that food can affect the absorption and distribution of the radioactive tracer that is injected into the bloodstream for the test, and that eating can also interfere with the quality of the images.

Choice C reason: I will ask the health care provider if the test can be rescheduled is not the best response by the nurse. This response may suggest that the nurse is not confident or knowledgeable about the test protocol or the client's condition. The nurse should explain the importance and urgency of the test and reassure the client that they will be able to eat after the test is done.

Choice D reason: The procedure is usually completed on an empty stomach is the best response by the nurse. This response is accurate and concise, and it informs the client of the standard preparation for the test. The nurse should also provide more details about the test procedure and the expected duration, and answer any questions or concerns that the client may have.

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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

A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Correct Answer is D

Explanation

The client, who is scheduled for a nuclear stress test, tells the nurse that the breakfast tray was not delivered and complains of hunger. The nurse's best response is:

Correct Answer is D

Explanation

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