Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Fatigue related to excessive fluid loss.

Deficient fluid volume related to dehydration.

Risk for impaired skin integrity related to irritation.

Imbalanced nutrition: less than body requirements related to vomiting.

Answer and Explanation

The Correct Answer is B

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

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Correct Answer is B

Explanation

Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).

The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.

An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.

This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.

Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.

A. Apply warm soaks to reduce the inflammation. B. Notify the health care provider immediately of the infection. C. Place the client on contact (wound) precautions. D. Document the findings and continue to monitor the wound.

Correct Answer is D

Explanation

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

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Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?

Correct Answer is B

Explanation

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Correct Answer is D

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

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Which client assessment should a nurse immediately report to the health care provider?

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