F&E #3

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis? Impaired urinary elimination Deficient fluid volume Imbalanced nutrition: Less than body requirements Excess fluid volume

Deficient fluid volume

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented. He has hot, dry skin and the following vital signs: a temperature of 100.6° F (38.1° C), a heart rate of 116 beats/minute, and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority? Deficient fluid volume related to osmotic diuresis Decreased cardiac output related to elevated heart rate Imbalanced nutrition: Less than body requirements related to insulin deficiency Ineffective thermoregulation related to dehydration

Deficient fluid volume related to osmotic diuresis

Which task is most important when developing a plan of care for a client with anorexia nervosa? Assessing laxative use Monitoring electrolyte levels Monitoring intake and output Evaluating exercise activities

Evaluating exercise activities

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Fear Urinary retention Excess fluid volume Toileting self-care deficit

Excess fluid volume

A client with benign prostatic hyperplasia (BPH) does not respond to medical treatment and is admitted to the facility for surgical intervention, transurethral resection of the prostate (TURP). In the postoperative period, the nurse reviews the laboratory values for which potential electrolyte imbalance? Hyponatremia Ketonuria Leukopenia Hypocalcemia

Hyponatremia

When caring for a child with acute glomerulonephritis, which action is a priority nursing intervention? Select all that apply. Measure daily weight. Increase oral fluid intake. Provide sodium supplements. Monitor the child for signs of hypokalemia. Assess for periorbital or dependent edema.

Measure daily weight. Assess for periorbital(IN EYE AREA) or dependent edema.

Which nursing intervention has the highest priority in the care of a 1-month-old infant admitted with projectile vomiting after feeding? Providing small, frequent, thickened feedings Positioning child on the right side Promoting breast-feeding Weighing the infant daily

Providing small, frequent, thickened feedings

A nurse is admitting a client with a suspected fluid imbalance. Which data gathered by the nurse is the most sensitive indicator of body fluid balance? monitor daily weight observe skin turgor measure intake and output obtain blood pressure

monitor daily weight

A client is admitted to the health care facility with nausea, vomiting, and abdominal cramps and distention. Which test result is most significant? Blood urea nitrogen (BUN) level of 29 mg/dl Serum sodium level of 132 mEq/L Urine specific gravity of 1.025 Serum potassium level of 3 mEq/L

Serum potassium level of 3 mEq/L

A client, 6 weeks' pregnant, is diagnosed with hyperemesis gravidarum. The nurse should monitor the client for the development of which condition? bowel perforation electrolyte imbalance miscarriage gestational hypertension

electrolyte imbalance