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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Sliced ham with green salad is not a good choice for a client who has diverticulitis. Diverticulitis is a condition where small pouches in the colon become inflamed or infected. The client should avoid foods that are high in fat, such as ham, or that contain seeds, nuts, or skins, such as green salad, as they can irritate the colon and worsen the symptoms.

Choice B reason: Pork tenderloin with green peas is not a suitable choice for a client who has diverticulitis. Pork tenderloin is a high-fat food that can increase the inflammation and pain in the colon. Green peas are also a source of fiber that can be hard to digest and can cause gas and bloating.

Choice C reason: Turkey sandwich with celery sticks is not an appropriate choice for a client who has diverticulitis. Turkey sandwich may contain mayonnaise, cheese, or other ingredients that are high in fat and can aggravate the condition. Celery sticks are high in fiber and have strings that can get trapped in the pouches and cause infection.

Choice D reason: Grilled chicken breast with white bread is the best choice for a client who has diverticulitis. Grilled chicken breast is a lean protein that can help the client heal and prevent malnutrition. White bread is a low-fiber food that can be easily digested and does not irritate the colon.

A. Monitoring respiratory status for signs and symptoms of pulmonary complications B. Encouraging the client to consume sodium-free fluids C. Weighing dressings with a large-bore catheter D. Drawing a blood sample for typing and cross-matching

Correct Answer is A

Explanation

Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.

Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.

Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.

Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?

Correct Answer is A

Explanation

The nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on?

Fluid and electrolyte balance is maintained through the process of fluid and solutes moving in and out of cells. What specific process allows fluid to pass through a membrane from a dilute to a more concentrated area?

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer)

A nurse is caring for a client who has cholecystitis with cholelithiasis and obstruction of the common bile duct. The nurse should expect the client's urine to appear which of the following colors?

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 caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

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

The nurse is providing care for a client with a fluid imbalance. The nurse explains that in the body, areas with high concentration of solutes naturally and passively shift to areas of lower concentration. The nurse is describing which process?