adaptive quizzes unit 4

Which response would a nurse give to the daughter of an 80-year-old client admitted to the hospital with severe dehydration who asks how her mother could have become dehydrated?

"Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid"

A client engages in angry outbursts and places excessive demands on the staff. An unlicensed health care worker tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." Which is the correct response by the nurse?

"The client is frightened and taking it out on the staff. Let's think of approaches we can take."

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which physiologic imbalance would the nurse most likely encounter?

Hypovolemia & Metabolic acidosis

During an 8-hour shift a client drinks two 6-oz (180-mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period? Record your answer using a whole number

235

When the registered nurse (RN) is assigning staff members to the care of clients on the unit, which situation represents an effective delegation decision by the RN?

An RN will administer enemas to a cardiac client until the enemas are clear

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration?

Changes in mental status

Which assessment would the nurse use to evaluate the severity of dehydration in a hospitalized infant with dry mucous membranes, absence of tears when the infant cries, and poor skin turgor?

Changes in weight from prior measurement

The registered nurse (RN) delegates a task to the licensed practical nurse (LPN). Which client task can be assigned to the LPN? A. Evaluate whether fluid electrolyte needs are being addressed with intravenous therapy. B. Perform sterile dressing changes on acute and chronic wounds . C. Notify the primary health care provider if client reports pain. D. Help with hearing aid placement.

Client B

Which diagnosis is suspected by the nurse when the laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco of 45 mm Hg, HCO of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L)?

Metabolic Acidosis

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO 89 mm Hg, PCO 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition?

Normal acid-base balance

Which electrolyte found in intracellular fluid would the nurse consider most important?

Potassium

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine?

Regularly offer the client a urinal

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?

Respiratory acidosis

Which ion is the regulator of extracellular osmolarity?

Sodium

Which information will the nurse include when teaching an unlicensed health care worker about blood pressure (BP) measurement?

Support the client's arm at heart level when taking BP & have the client rest for 5 minutes before measuring BP.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

The nurse identifies the client is not aware of perineal care and has impaired skin integrity.

Based on priority for care, which client condition would the nurse assign a red tag?

Third degree burns over 25% of total body surface area

Which strategy would the nurse provide unlicensed assistive personnel when caring for a child admitted to the hospital with severe diarrhea?

Weighing the child at the same time every day

Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure?

Weighing the client

Which scenario is a perfect example of primary prevention?

infant receiving a vaccine

Which physical findings that are typical in older adults would the nurse include when preparing to teach a community health program for senior citizens?

Increased blood pressure and decreased cardiac output