A nurse is caring for an older adult client who has gastroenteritis. Which of the following actions should the nurse take?
Wash hands for 10 seconds after caring for the client.
Monitor the client for manifestations of dehydration.
Use toilet paper to remove stool from the client's skin.
Administer diphenoxylate/atropine to the client.
The Correct Answer is B
A) "Wash hands for 10 seconds after caring for the client.": Proper hand hygiene is critical in preventing the spread of infections, but the recommended duration for handwashing is at least 20 seconds. This option does not specify the necessary steps to ensure effective hand hygiene.
B) "Monitor the client for manifestations of dehydration.": Older adults are at a higher risk of dehydration due to gastroenteritis, which can cause significant fluid loss through vomiting and diarrhea. Monitoring for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and reduced urine output, is a priority in managing their condition and preventing complications.
C) "Use toilet paper to remove stool from the client's skin.": While keeping the client clean is important, using toilet paper might not be sufficient or gentle enough to effectively clean and protect the skin. Using appropriate cleansing methods and skin care products is better for maintaining skin integrity.
D) "Administer diphenoxylate/atropine to the client.": While this medication can help reduce diarrhea, it may not be the first action to take. In some cases, stopping diarrhea too quickly can prevent the elimination of harmful pathogens. Monitoring and addressing hydration status is more critical initially in the management of gastroenteritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This method can help protect the ear from water exposure during showering or shampooing. However, it doesn't address trauma or hearing impairment prevention as effectively as avoiding pressure changes.
B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause trauma to the ear canal and potentially disrupt the surgical site, increasing the risk of complications and impairing hearing.
C) Avoid blowing your nose for 1 month after surgery.
Avoiding nose blowing is crucial because it can create pressure changes in the ear that may disrupt the healing process and cause trauma to the surgical site, leading to potential hearing impairment.
D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling sensations can be normal as the ear heals and adjusts post-surgery. While it’s important to monitor symptoms, reporting them is not necessarily about preventing trauma or hearing impairment.
Correct Answer is A
Explanation
A) Muscle twitching:
Muscle twitching, also known as tetany, is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to symptoms such as muscle cramps, spasms, and twitching. This is a key clinical sign that helps in diagnosing hypocalcemia.
B) Bounding pulse:
A bounding pulse is not typically associated with hypocalcemia. Instead, it is more often seen in conditions such as fluid overload or hyperdynamic circulatory states, where there is increased cardiac output or vascular volume.
C) Hypertension:
Hypertension is not a common manifestation of hypocalcemia. Hypocalcemia is more likely to cause hypotension due to its effect on cardiac contractility and vascular tone, rather than causing high blood pressure.
D) Decreased bowel sounds:
Decreased bowel sounds are not commonly associated with hypocalcemia. Hypocalcemia affects neuromuscular function, but it typically causes increased gastrointestinal motility rather than decreased motility, which would lead to hyperactive bowel sounds rather than decreased ones.
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