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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because a bounding pulse, hypertension, and distended neck veins are signs of fluid overload, which can occur during blood transfusions, especially in older adults.
Choice B reason: A thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload.
Choice C reason: Urticaria, itching, and wheezing suggest an allergic reaction, not fluid overload.
Choice D reason: Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload.
Correct Answer is C
Explanation
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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