A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake.

Slow the normal saline to a keep open rate while contacting the healthcare provider.

Review the client's medications to see if the client can be given a PRN diuretic.

Instruct the client to withhold oral fluids and report the symptoms to the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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Correct Answer is B

Explanation

Choice A reason: A bounding peripheral pulse indicates increased arterial circulation and is not a sign of compromised peripheral arterial circulation. In cases of arterial insufficiency, pulses may actually be diminished or absent.

Choice B reason: Uneven hair distribution is a classic sign of compromised peripheral arterial circulation. Poor blood flow to the extremities can lead to decreased hair growth, causing patchy or uneven hair distribution. This symptom is often seen in clients with peripheral arterial disease.

Choice C reason: Lower leg enema is more commonly associated with venous insufficiency rather than arterial insufficiency. Edem results from fluid accumulation due to poor venous return rather than issues with arterial circulation.

Choice D reason: Bronze pigmentation is often related to chronic venous insufficiency and hemosiderin deposition in the skin. It is not typically a sign of compromised arterial circulation. Arterial issues are more likely to cause pallor or cyanosis in the affected extremity.

A. Effectively manage pain, discomfort, and diarrhea. B. Ensure careful fluid and electrolyte balance. C. Reduce number and severity of acute exacerbations. D. Maintain a diet that is high in fibber content. I. In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

Choice A reason: Effectively managing pain, discomfort, and diarrhea is important for the client’s quality of life, but it does not address the long-term goal of preventing disease progression and complications.

Choice B reason: Ensuring careful fluid and electrolyte balance is critical, especially during acute exacerbations, but it is more of an immediate concern rather than a long-term goal.

Choice C reason: Reducing the number and severity of acute exacerbations is the most important long-term goal for clients with chronic ulcerative colitis. This goal focuses on maintaining remission, preventing complications, and improving overall prognosis by minimizing flare-ups.

Choice D reason: Maintaining a diet that is high in fibber content can be beneficial for overall health but may not always be suitable for clients with ulcerative colitis, especially during flare-ups. It is not the most critical long-term goal for managing the condition.

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A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Correct Answer is B

Explanation

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

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