A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority?
Auscultate the client's bowel sounds.
Measure the client's temperature.
Check the client's urine specific gravity.
Obtain the client's serum potassium level.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice B rationale:
“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.
Choice C rationale:
“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice D rationale:
“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The age of the client might influence the care plan and potential complications, but it's not the primary factor for evaluating cost effectiveness. Cost efficiency is more directly related to the resources utilized during the client's stay.
Choice B rationale:
The availability of community support groups contributes to the client's psychosocial well-being and support network, but it doesn't directly assist in evaluating the cost effectiveness of care. This factor focuses more on the quality of life after discharge.
Choice C rationale:
This is the correct choice. The length of the client's stay directly impacts the cost of care. A longer stay involves more resources, medications, and services, leading to increased costs. Evaluating and optimizing the length of stay is a critical aspect of cost-effective care.
Choice D rationale:
The type of insurance the client carries affects their financial responsibility for the care received, but it's not the main consideration for evaluating cost effectiveness. It primarily influences the patient's out-of-pocket expenses rather than the overall cost of care.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
The client does not have transportation for discharge home. Rationale: While transportation is important for discharge planning, it is not the priority concern in this situation. The client's immediate needs and well-being take precedence over transportation concerns.
Choice B rationale:
The client refuses to attend physical therapy sessions. Rationale: The correct choice. After a hip surgery, physical therapy is crucial for preventing complications, promoting mobility, and ensuring optimal recovery. The refusal to attend these sessions could lead to delayed healing, increased risk of complications, and impaired functional outcomes. Addressing the client's resistance to therapy is a priority to ensure the best possible recovery.
Choice C rationale:
The client's home health nurse has not completed the home assessment. Rationale: While a home assessment is important for discharge planning, it is not the most immediate concern. The client's refusal to attend physical therapy could have more immediate and significant effects on their recovery and well-being.
Choice D rationale:
The client describes feelings of depression after family visits. Rationale: While addressing the client's emotional well-being is important, it is not the priority concern in this situation. The refusal to attend physical therapy sessions could have physical consequences that take precedence over the emotional aspect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.