The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Inspection of lips and mucous membranes.

Pinches the skin on back of the hand.

Measures pulse and blood pressure.

Obtains client's daily weight.

Palpates scalp and hair distribution.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answers are Choices A, B, C, and D.Choice A rationale: Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale: Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale: Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale: Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale: Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.

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Correct Answer is C

Explanation

This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.

Some additional information for the response are:

Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.

Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.

Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.

Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).

A. Weigh the client. B. Observe skin turgor. C. Ask client about falls. D. Obtain blood pressure. E. Obtain blood sugar.

Correct Answer is ["A","E"]

Explanation

Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.

Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.

Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.

Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.

Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.

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The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Correct Answer is C

Explanation

A client is prescribed olanzapine for schizophrenia. How will the nurse monitor the client for adverse side effects? (Select all that apply).

Correct Answer is ["A","E"]

Explanation

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