The community health nurse is performing a home visit for a 74-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. The client states to stop drinking water early in the day because it's just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response?

You need to have your medications adjusted so you need to be admitted to the hospital for a complete workup.

You build up too much urine in your bladder, which can cause you to get confused.

Dehydration can cause changes that can result in confusion, so let's try to increase your fluid intake.

Urinary tract infections are common and can cause confusion, so it's important not to urinate at night.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: This statement is not the best response for the nurse to give. The surgeon will not encourage the client to limit their fat intake after an appendectomy, as this has nothing to do with the appendix. The appendix is a small pouch attached to the beginning of the large intestine, not the small intestine where most of the fat digestion and absorption occurs.

Choice B reason: This statement is not the best response for the nurse to give. The appendix does play a role in the immune system and the gut microbiome, as it contains lymphoid tissue and beneficial bacteria. The client may notice some changes in their immunity or digestion after an appendectomy, especially if they have an infection or take antibiotics.

Choice C reason: This statement is not the best response for the nurse to give. The appendix does not affect the absorption of nutrients from the food the client eats, as it is not involved in the digestive process. The appendix is located at the end of the small intestine, where most of the nutrients have already been absorbed.

Choice D reason: This statement is the best response for the nurse to give. The appendix is not essential for survival, and the small intestine can adapt to its removal over time. The client may experience some temporary symptoms such as diarrhea, bloating, or gas after an appendectomy, but these usually resolve within a few weeks. The nurse should reassure the client that they can live a normal and healthy life without an appendix.

A. Half-normal saline solution B. 10% dextrose in water C. 5% dextrose and half-normal saline solution D. Lactated Ringer's solution

Correct Answer is D

Explanation

Choice A reason: Half-normal saline solution is a hypotonic solution, which means it has a lower concentration of solutes than the blood plasma. It can cause fluid to shift from the blood vessels into the cells, leading to cellular swelling and edema.

Choice B reason: 10% dextrose in water is a hypertonic solution, which means it has a higher concentration of solutes than the blood plasma. It can cause fluid to shift from the cells into the blood vessels, leading to cellular shrinkage and dehydration.

Choice C reason: 5% dextrose and half-normal saline solution is a hypertonic solution, which has the same effects as choice B. The dextrose increases the osmolarity of the solution, while the half-normal saline provides some electrolytes.

Choice D reason: Lactated Ringer's solution is an isotonic solution, which means it has the same concentration of solutes as the blood plasma. It maintains fluid balance and provides electrolytes such as sodium, potassium, calcium, and lactate. It is commonly used for fluid resuscitation, dehydration, and acidosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

Correct Answer is D

Explanation

A physician orders an isotonic IV solution for a client. Which solution should the nurse plan to administer?

Correct Answer is D

Explanation

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

A nurse is discussing safety for administering intravenous fluids. Which condition might occur if hypertonic solutions are administered too quickly?

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholelithiasis. Which of the following findings should the nurse expect?

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the PRIORITY?

A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

The healthcare provider ordered an IV solution for a dehydrated client with a skull fracture. The nurse knows which IV fluid would be contraindicated?