The nurse is assessing the client's intake and output values for the shift (see chart below).

Intake for the shift

250mL Water

120mL Coffee

500mL Intravenous fluid

135 mL Orange Juice

120 mL Ice Cream

120 mL Jello

Output for the shift

545mL Urine

53mL Wound Drainage

200mL Emesis

375mL Urine

200mL Urine

75mL Loose Stool

480mL Urine

Based on these intake and output findings, what is the priority assessment by the nurse?

Palpate for pitting edema.

Assess for oral temperature.

Inspect the oral mucosa.

Auscultate adventitious lung sounds.

Answer and Explanation

The Correct Answer is C

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.

A. "The care team needs to cross-reference your diagnostic testing with your medical history." B. "In general, it's necessary for us to gather as much information about each client as possible." C. "We do not want to focus solely on the medical problem that brought you here." D. "This information will help me to plan individualized nursing care with you."

Correct Answer is D

Explanation

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a history of obesity. Upon palpation of the client's skin, the nurse notes diaphoresis. The client reports that, "it is always like that." The nurse should thoroughly inspect the skin on what part of the client's body?

Correct Answer is A

Explanation

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

Correct Answer is D

Explanation

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?