Exhibits
The client likely has
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The post-voided residual volume assessment is not part of a bladder retraining program but is a diagnostic tool used to assess bladder function after catheter removal. This explanation misrepresents the purpose of the procedure.
B. The post-voided residual volume assessment measures how much urine remains in the bladder after the client has voided. This measurement helps determine if the bladder is emptying properly and whether there is a need for catheter re-insertion.
C. Post-voided residual volume assessment does not stimulate the bladder to empty more completely; instead, it measures the amount of urine left in the bladder. The procedure is diagnostic rather than therapeutic.
D. The post-voided residual volume assessment is a diagnostic procedure, not an exercise in conditioning. This explanation does not accurately describe the clinical purpose of the assessment.
Correct Answer is B
Explanation
A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.
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