Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Palpate the rate and volume of the pulse.

Check fingernails for the presence of clubbing.

Measure body weight at the same time daily.

Observe the color and amount of urine.

Compare muscle strength of both arms.

Answer and Explanation

Correct Answer : A,C,D

The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of ﬂuid volume excess. These actions can help detect changes in the cardiovascular, renal, and ﬂuid balance systems that may indicate ﬂuid overloads, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.

The other options are not correct because:

B. Checking fingernails for the presence of clubbing is not relevant for assessing ﬂuid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.

E. Comparing muscle strength of both arms is not relevant for assessing ﬂuid volume excess, as muscle weakness is not a specific sign of ﬂuid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.

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Correct Answer is B

Explanation

- A bowel pattern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel pattern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.

- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patterns. It also includes inspecting and auscultating the abdomen for any abnormalities.

- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel pattern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because administering a stool softener without assessing the client's bowel pattern may not be appropriate or effective.

Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.

Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.

A. Tie the knot with a double turn or square knot. B. Ensure that the restraints are snug against the client's wrists. C. Move the ties so the restraints are secured to the side rails. D. Ensure that the knot can be quickly released.

Correct Answer is D

Explanation

Choice A: A double turn or square knot is not recommended because it is not a quick-release knot, which is necessary for patient safety in case of an emergency

Choice B: While restraints need to be secure, they should not be snug against the client's wrists. There should be enough space to fit two fingers between the restraint and the wrist to prevent circulation issues.

Choice C: Ties should not be secured to side rails as this can cause injury if the rails are moved. Instead, they should be attached to the movable part of the bed frame.

Choice D: This is the correct action. A half-bow knot is a type of quick-release knot, which is essential for the safety and quick release of the patient if needed

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Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Correct Answer is B

Explanation

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Correct Answer is D

Explanation

Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?

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A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

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The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?