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A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Which of the following statements should the nurse include in the client's teaching?

Select all that apply.

Try using an abdominal support belt

Take hot showers to help relieve itching"

"Wear loose-fitting clothing"

"Eat two large meals a day."

You should avoid fried foods"

Answer and Explanation

Correct Answer : C,D,G

Choice A reason:

"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.

Choice B reason:

"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.

Choice C reason:

"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.

Choice D reason:

"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.

Choice E reason:

"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.

Choice F reason:

"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.

Choice G reason:

"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.

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Correct Answer is C

Explanation

A. Incorrect. Headache can be associated with various conditions, but it is not a specific manifestation of hypovolemia.
B. Incorrect. Shortness of breath can occur in conditions affecting the respiratory system, such as pneumonia or asthma, but it is not a primary manifestation of hypovolemia.
C. Correct. Dizziness is a common manifestation of hypovolemia due to decreased blood volume and inadequate perfusion to the brain.
D. Incorrect. Epistaxis (nosebleed) might not be directly related to hypovolemia. It could be associated with other factors, such as dry air or nasal irritation.

A. Confirm that the client is able to urinate. B. Check the client's serum albumin levels. C. Compare the client's current weight with preprocedure weight. D. Examine for leakage at the site of the procedure.

Correct Answer is C

Explanation

A. Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B. Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C. Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D. Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.

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A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)