A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

Decreased NG tube drainage.

Potassium 3.3 mEq/L.

Increased heart rate.

Hematocrit 46%.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.

Choice B rationale:

The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice C rationale:

An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice D rationale:

A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.

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Correct Answer is C

Explanation

Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to managing dry mouth caused by benztropine. While fiber is essential for digestive health, it does not directly address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can be helpful in promoting saliva production, but in Parkinson's disease, it can exacerbate swallowing difficulties and increase the risk of aspiration.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the appropriate recommendation. Lemon-glycerin swabs can help lubricate the mouth and provide relief from dryness, which is a common side effect of benztropine, an anticholinergic medication.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat oral candidiasis (thrush), a fungal infection, and is not relevant to managing dry mouth caused by benztropine.

A. "Schedule all physical activities for the morning hours.". B. "When taking fingolimod, you should monitor your blood pressure.". C. "Avoid rigorous activities that increase body temperature.". D. "Corticosteroids should be taken daily for the rest of your life.".

Correct Answer is C

Explanation

Choice A rationale:

The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.

Choice B rationale:

Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.

Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.

Choice C rationale:

This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.

Choice D rationale:

Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.

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A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Parkinson's disease and is taking benztropine and reports experiencing a dry mouth. Which of the following recommendations should the nurse make?

Correct Answer is C

Explanation

A nurse is providing teaching about disease management to a client who has multiple sclerosis. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

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