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 A

Explanation

The correct answer is choice A: A nurse is photocopying their assigned client's diagnostic test results.

Choice A rationale: The charge nurse should intervene because photocopying a client's diagnostic test results can pose a potential breach of confidentiality and privacy. Unless there is a specific and authorized reason, personal health information should not be copied or removed from the client's medical record.

Choice B rationale: An assistive personnel (AP) documenting a client's vital signs on the client's paper-based graphic record is a routine task and does not require intervention by the charge nurse.

Choice C rationale: The unit secretary faxing a client's laboratory results to the provider is a standard practice for sharing necessary health information with the care team. No intervention is required.

Choice D rationale: An RN staying with a client who is reading their requested medical records is appropriate. Clients have the right to access their own medical records, and the nurse's presence can help address any questions or concerns the client might have while reviewing their records.

A. Occupational therapy B. Social services C. Home health D. Physical therapy

Correct Answer is B

Explanation

The correct answer is b. Social services.

Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.

Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.

Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.

Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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