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. While it’s important to keep the client calm, this task may not be the most critical or appropriate for a UAP in an emergency situation. The nurse typically leads in managing the client's immediate needs.
B. This is a crucial task because the PN will need sterile supplies (e.g., sterile saline, dressings) to manage the evisceration. The UAP can efficiently gather these supplies, allowing the PN to focus on assessing the client and providing immediate care. This delegation is appropriate because it helps expedite the response to a critical situation.
C. Covering the wound is a critical step in managing evisceration, which should be performed by the PN to ensure it is done correctly and to maintain sterile technique. The PN is responsible for the clinical management of the emergency.
D. Repositioning the client could exacerbate the situation or delay necessary interventions. The PN must assess and manage the evisceration while ensuring the client remains as stable as possible.
Correct Answer is A
Explanation
A. Instructing the UAP to lower the bed for safety is the correct action. The bed should be in a low position to prevent falls and ensure safety during client care activities.
B. Determining if the UAP would like assistance is not the most effective immediate action. The priority is to address the safety concern of the bed position rather than offering assistance.
C. Remaining in the room to supervise the UAP is less effective than directly addressing the safety issue. The bed should be in the proper position for safe client care.
D. Assuming care of the client immediately is not necessary unless there are additional concerns about the client's well-being. The primary action should be to correct the unsafe practice of the bed position.
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