a nurse is assessing a client for signs of dehydration which of the following findings should the nurse look for
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A healthcare professional is assessing a client for signs of dehydration. Which of the following findings should the healthcare professional look for?

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration. In dehydration, the body loses more water than it takes in, leading to dryness of mucous membranes like the mouth and throat. Edema (choice A) is swelling caused by excess fluid trapped in the body's tissues, which is not a typical sign of dehydration. Weight gain (choice C) is also not a common sign of dehydration; in fact, dehydration usually leads to weight loss. Increased urination (choice D) is more indicative of conditions like diabetes or diuretic use, not dehydration.

2. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?

Correct answer: C

Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.

3. A healthcare professional is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?

Correct answer: A

Rationale: The correct answer is A: '2'. Gastric contents with a pH between 0 and 4 provide a good indication of appropriate tube placement. A pH of 2 is within this range, indicating that the tube is correctly placed in the stomach. Choices B, C, and D are incorrect because a pH of 5, 7, or 9 does not fall within the expected acidic pH range of gastric fluid.

4. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The priority action is to verify the prescription with the provider. Verifying the prescription ensures patient safety by preventing fluid volume overload and dysrhythmias, which can result from infusing potassium too rapidly. Teaching the client about IV extravasation, evaluating IV patency, and consulting with the pharmacist are important but should come after verifying the prescription to ensure the ordered treatment is appropriate and safe for the client's condition.

5. A nurse is providing teaching to a client who has chronic kidney disease. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Clients with chronic kidney disease should limit their intake of phosphorus because high phosphorus levels can lead to bone disease and cardiovascular problems. Increasing foods high in potassium (choice B) is not recommended as it can be harmful to individuals with kidney disease. Decreasing intake of foods high in iron (choice C) is not specifically indicated for chronic kidney disease. Increasing calcium supplements (choice D) may not be necessary and can potentially lead to hypercalcemia in individuals with kidney disease.

Similar Questions

A client who is having suicidal thoughts tells the nurse, “It just doesn’t seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?
A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client's membranes have ruptured?
A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?
A provider has written a do not resuscitate (DNR) order for a client who is comatose and does not have advance directives. A member of the client’s family says, 'I wonder when the doctor will tell us what’s going on.' Which of the following actions should the nurse take first?
During a skin assessment on a client with risk factors for skin cancer, a nurse should understand that a suspicious lesion is:

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses