The nurse is assessing a 66-year-old client who reports having a fever and feeling weak and dizzy with nausea and vomiting for three days. The nurse observes a dry tongue and oral mucosa, and concentrated urine. To best assess the client's fluid status, which parameter(s) should the nurse check?
Temperature
BP and pulse in lying, then sitting and standing positions
Pulse oximetry reading on room air
Respiratory rate and depth
The Correct Answer is B
A. Temperature: While temperature assessment is important in evaluating a client's condition, it primarily indicates the presence of fever, which the client already reports. However, it does not provide direct information about the client's fluid status.
B. BP and pulse in lying, then sitting and standing positions: Assessing blood pressure (BP) and pulse in different positions (lying, sitting, and standing) helps evaluate orthostatic changes, which can indicate volume depletion or dehydration. A drop in BP and an increase in pulse rate upon standing suggest volume depletion and orthostatic hypotension, which are indicators of fluid loss.
C. Pulse oximetry reading on room air: Pulse oximetry measures the oxygen saturation of arterial blood and is primarily used to assess respiratory status and oxygenation. While it provides valuable information about oxygen levels, it does not directly assess fluid status.
D. Respiratory rate and depth: Respiratory rate and depth can be affected by various factors, including pain, fever, and respiratory conditions. While changes in respiratory rate and depth can indicate distress or respiratory compromise, they are not specific indicators of fluid status and may not directly reflect hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Milk and cheese: While milk and cheese are sources of calcium and protein, they are not typically recommended as primary dietary choices for preventing or treating constipation. In fact, for some individuals, dairy products can contribute to constipation, particularly if they are consumed in excess or if the individual is lactose intolerant.
B. Lean meats: Lean meats provide protein and essential nutrients but are not specifically known for their role in preventing or treating constipation. While protein is important for overall health, focusing solely on lean meats may not provide the dietary fiber needed to promote regular bowel movements.
C. Fruit and vegetables: This statement is correct. Fruit and vegetables are rich sources of dietary fiber, which plays a crucial role in promoting healthy bowel function and preventing constipation. Fiber adds bulk to the stool, making it easier to pass through the digestive tract. Fruits such as apples, berries, and pears, as well as vegetables like broccoli, spinach, and carrots, are particularly high in fiber and can help alleviate constipation when included in the diet.
D. Bread and pasta: Bread and pasta are sources of carbohydrates, but they may not necessarily contain high levels of dietary fiber, especially if they are made from refined grains. While whole grain bread and pasta can provide more fiber than their refined counterparts, they may not be as effective in preventing or treating constipation compared to fruits and vegetables, which are naturally rich in fiber.
Correct Answer is ["B","C","D"]
Explanation
A. Reading back the calcium level result to the lab technician: Reading back results to the lab technician is a good practice to ensure accurate communication. The nurse verifies that they have received the correct information and confirms the accuracy of the result.
B. Document the time the call was received & the lab technician's name and date of birth. This was not selected because while documenting the time of the call and the lab technician's information may be useful for record-keeping purposes, it is not directly related to the immediate management of the client's low calcium level. Therefore, it is not essential to the immediate actions required in response to the lab result.
C. Reporting the elevated calcium level to the client's physician: An abnormally low calcium level (hypocalcemia) of 6.3 mg/dL requires prompt notification to the client's physician for further evaluation and intervention.
D. Confirming the client's full name, date of birth, & medical record number with the lab technician: Verifying the client's identity and medical record number ensures that the lab results are correctly matched to the right patient, minimizing the risk of errors in patient care.
E. Documenting the low calcium level in the client's electronic medical record: Documenting the calcium level in the client's electronic medical record ensures that the result is recorded for future reference and continuity of care. Accurate documentation is essential for tracking the client's health status and treatment outcomes.
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