A nurse is caring for a client with suspected viral gastroenteritis. What assessment finding should the nurse prioritize?
Skin turgor and mucous membranes
Blood pressure and heart rate
Urinary output and specific gravity
Respiratory rate and lung sounds
The Correct Answer is A
A) Correct. Skin turgor and mucous membranes are important indicators of hydration status, which is a critical concern in clients with gastroenteritis.
B) Incorrect. While blood pressure and heart rate are important vital signs, they may not provide immediate information about the client's hydration status.
C) Incorrect. Urinary output and specific gravity are important indicators of renal function, but they may not provide immediate information about the client's hydration status.
D) Incorrect. Respiratory rate and lung sounds are important assessments, but they may not provide immediate information about the client's hydration status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Electrolytes are primarily absorbed in the small intestine, not the large intestine.
B) Correct. Gastroenteritis can lead to electrolyte imbalances, especially when there is excessive vomiting and diarrhea, as these processes result in the loss of important electrolytes.
C) Incorrect. Gastroenteritis can lead to electrolyte imbalances, so electrolyte levels may not remain stable in affected individuals.
D) Incorrect. Electrolytes play a crucial role in various physiological processes, and their imbalance is a significant aspect of the pathophysiology of gastroenteritis.
Correct Answer is A
Explanation
A) Correct. This advice encourages the client to monitor their temperature and take appropriate action if it rises significantly.
B) Incorrect. While a fever is expected with gastroenteritis, it can still be managed to improve the client's comfort.
C) Incorrect. Ibuprofen may not be the best choice for everyone, and it's important to specify a temperature threshold for intervention.
D) Incorrect. A fever of 100°F (37.8°C) is not a critical threshold that would necessitate an immediate visit to the emergency room.
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