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 D
Explanation
Choice A rationale:
A nurse cannot provide basic treatment information to the client's employer without the client's explicit consent. This information falls under the client's confidentiality rights and cannot be shared without proper authorization.
Choice B rationale:
While a nurse can inform the client about the risks and benefits of electroconvulsive therapy, this statement does not encompass the entirety of the client's rights. Clients have the right to be informed about the risks and benefits of all treatments, not just electroconvulsive therapy.
Choice C rationale:
Clients on a mental health unit who are admitted voluntarily have the right to leave against medical advice, as long as they are deemed capable of making that decision. Voluntary admission does not negate a client's autonomy to make decisions about their own care.
Choice D rationale:
The correct answer. Clients on a mental health unit have the right to refuse their medication, as long as they are deemed competent to make that decision. This is an important aspect of respecting a client's autonomy and informed consent, even in a mental health setting. However, if a client's refusal poses a serious risk to their health or the health of others, healthcare providers may need to take appropriate actions while respecting legal and ethical standards.
Correct Answer is C
Explanation
Choice A rationale:
Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.
Choice B rationale:
Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.
Choice C rationale:
Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.
Choice D rationale:
Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.
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