Older adults can suffer from fluid volume deficits and excesses. What assessments
can we do to determine each problem?
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For fluid volume deficits, the clients would have tented skin when pinched
and deep tongue grooves. In fluid volume excess, the client could have
crackles when auscultating breath sounds and weight gain. To increase fluid
intake, assess client fluid preferences and push fluids (2L a day). Diuretics to
take off fluids.
What is the most important action a nurse can take before administering a blood
product?
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, Make sure there is a consent signed for the blood and then verify the
blood group and type with a second nurse.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day.
What question is most important for the nurse to include during the preoperative
assessment?
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What vitamin and mineral supplements do you take?
What color stool do you expect from a patient with an upper GI bleed?
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The stool would be thick, black, and tarry from traveling the entire intestinal
tract.
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
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Encourage additional oral intake of juices and water
,When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse
take next?
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Record the amount on the client's fluid output record.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What
instructions should the nurse give the UAP?
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Report the results of the vital signs to the nurse.
When assessing a male client, the nurse finds that he is fatigued, and is experiencing
muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the
nurse plans to check the client's laboratory values to validate the existence of which?
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Hypokalemia- muscle weakness, leg cramps, and cardiac dysrhythmias.
Normal range is 3.5- 5.0.
A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
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demonstrates the wound care procedure correctly.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair,
the client starts to fall. Which is the priority action for the nurse to take?
Give this one a try later!
Gently lower the client to the floor.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chain of infection?
Give this one a try later!
Mode of transmission
When entering the room of an adult male, the nurse finds that the client is very
anxious. Before providing care, what action should the nurse take first?
Give this one a try later!
Re-assess the client situation
can we do to determine each problem?
Give this one a try later!
For fluid volume deficits, the clients would have tented skin when pinched
and deep tongue grooves. In fluid volume excess, the client could have
crackles when auscultating breath sounds and weight gain. To increase fluid
intake, assess client fluid preferences and push fluids (2L a day). Diuretics to
take off fluids.
What is the most important action a nurse can take before administering a blood
product?
Give this one a try later!
, Make sure there is a consent signed for the blood and then verify the
blood group and type with a second nurse.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day.
What question is most important for the nurse to include during the preoperative
assessment?
Give this one a try later!
What vitamin and mineral supplements do you take?
What color stool do you expect from a patient with an upper GI bleed?
Give this one a try later!
The stool would be thick, black, and tarry from traveling the entire intestinal
tract.
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
Give this one a try later!
Encourage additional oral intake of juices and water
,When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse
take next?
Give this one a try later!
Record the amount on the client's fluid output record.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What
instructions should the nurse give the UAP?
Give this one a try later!
Report the results of the vital signs to the nurse.
When assessing a male client, the nurse finds that he is fatigued, and is experiencing
muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the
nurse plans to check the client's laboratory values to validate the existence of which?
Give this one a try later!
Hypokalemia- muscle weakness, leg cramps, and cardiac dysrhythmias.
Normal range is 3.5- 5.0.
A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
, Give this one a try later!
demonstrates the wound care procedure correctly.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair,
the client starts to fall. Which is the priority action for the nurse to take?
Give this one a try later!
Gently lower the client to the floor.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chain of infection?
Give this one a try later!
Mode of transmission
When entering the room of an adult male, the nurse finds that the client is very
anxious. Before providing care, what action should the nurse take first?
Give this one a try later!
Re-assess the client situation
