A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

Encourage the client to use guided imagery to relax.

Elevate the head of the client's bed.

Increase the client's fluid intake.

Instruct the client to perform the Valsalva maneuver.

Answer and Explanation

The Correct Answer is C

Choice A reason : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.

Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].

Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.

Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].

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Correct Answer is D

Explanation

Choice A reason : Thickened toenails are often associated with fungal infections and are not a direct symptom of venous insufficiency. However, they can appear in patients with chronic venous insufficiency due to poor circulation that affects the health of the toenails.

Choice B reason : Shiny, thin skin on the lower extremities is more characteristic of arterial insufficiency, where there is a reduction in blood flow and oxygen to the tissues. In venous insufficiency, the skin may instead appear thickened and discolored due to stasis and buildup of hemosiderin from the breakdown of red blood cells.

Choice C reason : A dusky, red color of the feet when dangling can be a sign of dependent rubor, which is associated with arterial insufficiency. This occurs when there is a severe decrease in arterial blood flow to the lower extremities. Venous insufficiency may cause a different color change, typically a brownish discoloration due to hemosiderin deposition.

Choice D reason : Pitting edema is a hallmark sign of venous insufficiency. It occurs due to the accumulation of fluid in the tissues, which is a result of increased pressure in the veins. This pressure causes fluid to leak into the surrounding tissues, leading to swelling that retains an indentation when pressed.

Correct Answer is ["2"]

Explanation

Step 1 is to identify the prescribed dose of digoxin, which is 0.25 mg.

Step 2 is to identify the amount of digoxin available per tablet, which is 0.125 mg/tablet.

Step 3 is to calculate the number of tablets the nurse should administer per dose. This is done by dividing the prescribed dose by the amount available per tablet. So, 0.25 mg ÷ 0.125 mg/tablet = 2 tablets.

The nurse should administer 2 tablets per dose.

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A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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