A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

BUN 18 mg/dL.

A thready pulse.

Hemoglobin 15 g/dL.

Prominent neck veins.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: A thready pulse.

Choice A rationale:

BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.

Choice B rationale:

A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.

Choice C rationale:

Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.

Choice D rationale:

Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.

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Correct Answer is B

Explanation

The correct answer is choice B. Remove the cover gown in the client’s room after providing care. This is because Clostridium difficile spores are not effectively killed by alcohol-based hand rubs and can survive on surfaces for a long time. Removing the gown in the client’s room helps to contain any spores that may have settled on the gown, preventing them from being spread to other areas.

Choice A rationale:

Cleaning hands with an alcohol-based hand rub immediately after removing gloves is wrong because C. difficile spores are resistant to alcohol-based hand rubs. The recommended practice is thorough handwashing with soap and water to physically remove the spores from the hands.

Choice C rationale:

Placing the client in a room with negative-pressure airflow is wrong because this measure is used for airborne infections, such as tuberculosis. C. difficile is spread via the fecal-oral route, primarily through contact with contaminated surfaces or hands, not through the air.

Choice D rationale:

Wearing a mask when administering oral medications to the client is wrong because C. difficile is not spread through respiratory droplets. Masks are not necessary unless there is a risk of splash or spray of contaminated material.

A. An insurance agency offering a life insurance policy. B. A family member who requests the client's diagnosis. C. A physical therapist who is involved in the client's care. D. An employer completing a pre-employment screening.

Correct Answer is C

Explanation

The correct answer is choice C: A physical therapist who is involved in the client's care.

Choice A rationale:

Disclosing health information to an insurance agency offering a life insurance policy typically requires the client's written permission due to the sensitive nature of the information being shared, including medical history and conditions.

Choice B rationale:

Revealing a client's diagnosis to a family member without written consent would violate the client's privacy rights. Health information is protected by privacy laws, and disclosure should only occur with the client's explicit permission.

Choice C rationale:

This is the correct entity to whom health information can be disclosed without the client's written permission. Health professionals who are actively involved in the client's care, such as a physical therapist, are considered part of the healthcare team and may need access to relevant health information for proper treatment.

Choice D rationale:

Disclosing health information to an employer completing a pre-employment screening generally requires the client's consent, as pre-employment screenings often involve sharing medical information that could impact the employment decision.

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A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Correct Answer is B

Explanation

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

Correct Answer is C

Explanation

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