Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Heart rate 99 beats/minute

Dark, yellow urine

Urinated 30 mL

Temperature 101° F (38.3° C)

Answer and Explanation

Correct Answer : A,B,C

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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Correct Answer is A

Explanation

A. Understanding the client’s current and previous sleep habits and cycles is the most foundational step for assessing sleep disturbances. This information provides a baseline from which the PN can identify patterns and deviations in the client’s sleep behavior.
B. While evening meal and snacking habits can affect sleep, they are secondary to understanding the client’s overall sleep habits and cycles. These habits are part of a broader assessment but not the initial focus.
C. Identifying symptoms resulting from sleep disturbances is important but follows after understanding the client’s sleep history. Symptoms are a result of disturbances, and their identification is based on a foundational understanding of sleep patterns.
D. Exploring new sleep routines the client is considering is part of the intervention phase but comes after understanding current sleep patterns and disturbances. The initial focus should be on gathering comprehensive sleep history.

A. Re-lubricate the tubing and re-insert it. B. Insert the tubing an additional three inches into the rectum. C. Raise the saline container six inches higher. D. Instruct the client to take several slow, deep breaths.

Correct Answer is B

Explanation

A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.

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Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

Correct Answer is A

Explanation

When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

Correct Answer is B

Explanation

A 2-month-old client is brought to the well-baby clinic. The parent is completing the consent forms for routine infant immunizations. Which immunization should the practical nurse (PN) prepare to administer?

Exhibits The practical nurse (PN) would like to encourage the client to take oral fluids so that the IV fluids can eventually be discontinued. Which three strategies would be most effective in getting a client to consume adequate oral fluids?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. What client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? Select all that apply.

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?

Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?