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.

Answer and Explanation

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.

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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.

A. Place the client in a dorsal recumbent position for the examination. B. Auscultate for vascular bruits with the diaphragm of the stethoscope. C. Begin the assessment by using light palpation over the abdomen. D. Ensure that the client has a full bladder before beginning the procedure.

Correct Answer is A

Explanation

The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.

Choice A rationale:

The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.

Choice B rationale:

Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.

Choice C rationale:

The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.

Choice D rationale:

The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.

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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?

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