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 B
Explanation
Choice A reason: Risk for injury is a potential nursing diagnosis for a client who recently experienced a stroke, but it is not the priority. Risk for injury is related to the possible complications of stroke, such as hemiparesis, hemiplegia, dysphagia, or sensory deficits, that may increase the risk of falls, aspiration, or pressure ulcers. However, these complications are secondary to the primary problem of altered cerebral perfusion, which is the cause of stroke.
Choice B reason: Altered cerebral perfusion is the priority nursing diagnosis for a client who recently experienced a stroke, because it is the most urgent and life-threatening problem. Altered cerebral perfusion is defined as a decrease in blood flow to the brain, which can result in ischemia, infarction, or hemorrhage of the brain tissue. This can lead to irreversible neurological damage, disability, or death. Therefore, the nurse should focus on restoring and maintaining adequate cerebral perfusion as the first priority.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.
Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.
Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.
Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.
Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.
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