A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)

Hypotension

Bradycardia

Pale yellow urine

Poor skin turgor

Flat neck veins

Answer and Explanation

Correct Answer : A,D,E

A.   Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B.   Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C.   Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D.   Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E.   Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.

Choice B rationale

Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.

Choice C rationale

Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.

Choice D rationale

Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.

A. Change gloves between tasks on the same client B. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile C. Use alcohol-based hand rubs before administering eye drops for a client D. Keep artificial nails trimmed short E. Keep artificial nails trimmed short

Correct Answer is A

Explanation

Choice A rationale

Changing gloves between tasks on the same client is a key infection control practice. This prevents cross-contamination between different body sites and reduces the risk of spreading infection.

Choice B rationale

Washing hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile is not recommended. Clostridium difficile spores are not killed by alcohol-based hand rubs. Handwashing with soap and water is more effective.

Choice C rationale

Using alcohol-based hand rubs before administering eye drops for a client is a good practice, but it is not the most important information to reinforce. Hand hygiene is crucial in all aspects of patient care to prevent the spread of infection.

Choice D rationale

Keeping artificial nails trimmed short is a good practice, but it is not the most important information to reinforce. Artificial nails can harbor bacteria and other pathogens, increasing the risk of infection transmission.

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A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

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A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)