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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Temperature 99.9° F (37.7° C)

Respirations 34 breaths/minute

Heart rate 136 beats/minute

Weak peripheral pulses

Dry mucous membranes

Body mass index (BMI) 21.9 kg/m2

Blood pressure 100/52 mm Hg

Poor skin turgor

Answer and Explanation

Correct Answer : C,D,E,G,H

A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.

B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.

C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.

D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.

E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.

F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.

G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.

H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.

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Correct Answer is A

Explanation

A. Yogurt or buttermilk: Cefdinir can disrupt the normal balance of bacteria in the gut. Yogurt or buttermilk, which contain probiotics, can help restore beneficial bacteria and reduce the risk of gastrointestinal complications such as antibiotic-associated diarrhea.

B. Avocados and cheese: While these are healthy foods, they do not specifically support gut health in the same way that probiotics do. Additionally, cheese may be high in fat and could potentially exacerbate gastrointestinal discomfort.

C. Fresh fruits: Fresh fruits provide important vitamins and fiber, but they do not specifically target the restoration of normal gut flora. Some fruits may also be difficult for a client with a postoperative wound infection to tolerate, especially if they are experiencing digestive issues.

D. Green leafy vegetables: While green leafy vegetables are nutritious, they do not have a direct role in supporting gut flora during antibiotic therapy. They are rich in vitamins and minerals, but the focus should be on probiotics like yogurt or buttermilk.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Rationale for Correct Choices:

Impaired physical mobility: Rheumatoid arthritis leads to joint inflammation, stiffness, and potential deformities. These symptoms may result in decreased range of motion and difficulty with physical movements, contributing to impaired mobility.
Acute pain: RA causes acute inflammation in the joints, resulting in pain, especially during flare-ups. The client experiences pain and stiffness in the hands and wrists, which aligns with the acute pain risk associated with RA.
Knowledge deficit: Newly diagnosed RA patients often lack understanding about the disease process, treatment options, and lifestyle modifications. The nurse needs to recognize that the client requires education to manage their condition effectively and understand the long-term implications.

Rationale for Incorrect Choices:

Electrolyte imbalance: Electrolyte imbalances are not a typical complication of rheumatoid arthritis. While certain medications used to treat RA (like corticosteroids) can impact electrolyte levels, this is not an immediate concern or a direct risk associated with RA itself.

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Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

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Exhibits

The nurse reviews the intake information prior to seeing the client.

What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.