An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Keep room temperature cool.

Determine the client's food preferences.

Maintain a patent intravenous site.

Teach the client relaxation techniques.

Answer and Explanation

The Correct Answer is C

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

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Correct Answer is B

Explanation

Choice A reason: Using extra pillows may help with comfort but is not the basis of the nurse's response to the concern about thoracentesis.

Choice B reason:

The correct answer is b) because during thoracentesis, the client is positioned upright, which helps ease breathing and access the pleural space.

Choice C reason: While the procedure may be brief, this response does not directly address the concern about breathing.

Choice D reason: Orthopnea can be caused by conditions other than anxiety and should be addressed appropriately.

A. Washes the radiation site with antibacterial soap and water. B. Dries the area with patting motions after taking a shower. C. Applies prescribed lotions to the radiation site. D. Wears clothing to cover the radiation site.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because using antibacterial soap can be too harsh and irritating for the skin that is undergoing radiation treatment. Gentle cleansing with mild soap is recommended to avoid skin irritation.

Choice B reason: Drying the area with patting motions is appropriate as it helps prevent further irritation to the sensitive skin.

Choice C reason: Applying prescribed lotions is recommended to keep the skin moisturized and help with any radiation-induced dryness or irritation.

Choice D reason: Wearing clothing to cover the radiation site can protect the area from sun exposure and further irritation, which is appropriate care for the skin.

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An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

Correct Answer is B

Explanation

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Correct Answer is A

Explanation

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