The nurse notices that an older adult’s urine is concentrated. Which step should the nurse implement next?
Evaluate the medication list
Review laboratory reports
Increase oral fluid intake
Determine fluid volume status
The Correct Answer is D
Choice A reason: Evaluating the medication list is a possible step that the nurse can take, as some medications can affect urine concentration or cause dehydration. However, it is not the first step that the nurse should implement, as it does not address the immediate problem of fluid balance.
Choice B reason: Reviewing laboratory reports is another possible step that the nurse can take, as some laboratory tests can indicate the level of hydration or kidney function of the patient. However, it is not the first step that the nurse should implement, as it does not provide a direct assessment of fluid status.
Choice C reason: Increasing oral fluid intake is a potential intervention that the nurse can suggest, as it can help to dilute the urine and prevent dehydration. However, it is not the first step that the nurse should implement, as it may not be appropriate for some patients who have fluid restrictions or other medical conditions.
Choice D reason: Determining fluid volume status is the first step that the nurse should implement, as it can help to identify the cause and severity of urine concentration and guide further actions. The nurse can assess the patient's fluid intake and output, weight, blood pressure, pulse, skin turgor, mucous membranes, and urine specific gravity to determine fluid volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Improper assistive device use contributes to older adult falls is a true statement, as it is supported by evidence from web search results. According to the Age Space guide to assistive technology for the elderly, "it is important to ensure that the device is used correctly and safely, as improper use can increase the risk of falls and injuries." Similarly, according to the AAFP article on mobility assistive device use in older adults, "improper use of assistive devices can lead to falls, injuries, and decreased mobility."
Choice B reason: Older adults save money by adopting assistive devices from their friends is not a true statement, as it is not recommended by experts. According to the AAFP article on mobility assistive device use in older adults, "borrowing devices from friends or family members is not advised because devices may not be properly fitted or maintained, and may not meet the patient's needs."
Choice C reason: A walker can be used when climbing stairs is not a true statement, as it is not safe or feasible. According to the NICHD article on types of assistive devices and their use, "walkers are not designed for use on stairs or escalators."
Choice D reason: Cane tips should be smooth is not a true statement, as it is contrary to the best practice. According to the AAFP article on mobility assistive device use in older adults, "cane tips should have a nonskid surface to prevent slipping."
Choice E reason: None of the above is not the correct answer, as there is one choice that is a true statement about assistive devices to aid older adults with impaired mobility.
Correct Answer is B
Explanation
Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.
Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.
Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.
Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.
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