a nurse is assessing a client for signs of dehydration which of the following findings should the nurse look for
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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 is caring for a client who has a prescription for vancomycin 1 g IV every 12 hours. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

Correct answer: D

Rationale: The trough level of vancomycin should be drawn just before the next dose is administered, typically about 30 minutes before the scheduled dose. Since the morning dose is at 0700, the trough level should be drawn at 1800. This timing ensures an accurate measurement of the lowest concentration of the drug in the client's system before the next dose is given. Choice A (2100) is too close to the next dose, choice B (900) is too early, and choice C (1300) is also too far from the next dose.

3. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?

Correct answer: A

Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.

4. A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?

Correct answer: B

Rationale: The correct answer is to verify the client's blood glucose level first before administering insulin. This step is crucial to determine the appropriate dose of insulin based on the client's current blood glucose level. Checking the expiration date (Choice A) is important but not the first step in this scenario. Obtaining the client's weight (Choice C) is not directly related to the immediate administration of insulin. Assessing for signs of hypoglycemia (Choice D) should be done after administering insulin to monitor for potential side effects or adverse reactions.

5. A healthcare professional is planning a community education program about colorectal cancer. Which of the following risk factors should the professional identify as modifiable?

Correct answer: B

Rationale: The correct answer is B: Smoking. Smoking is a modifiable risk factor for colorectal cancer. It is within an individual's control to quit smoking, thereby reducing their risk of developing colorectal cancer. Choices A, C, and D are non-modifiable risk factors. Family history, age, and gender are factors that individuals cannot change or control. While family history can influence risk, it is not something that can be modified. Age and gender are also non-modifiable factors when it comes to colorectal cancer risk.

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