which intervention is essential for a client with dehydration
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Nursing Elites

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1. What intervention is essential for a client with dehydration?

Correct answer: B

Rationale: Administering oral rehydration solutions is essential for a client with dehydration as it helps replenish lost fluids and electrolytes directly through the oral route. Monitoring electrolyte levels regularly (Choice A) is important but not as essential as providing immediate rehydration. Increasing fluid intake to maintain hydration (Choice C) may not be sufficient for a client already dehydrated and needing rapid replenishment. Administering intravenous fluids (Choice D) is a more invasive intervention typically reserved for severe cases of dehydration or when the client cannot tolerate oral fluids.

2. During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?

Correct answer: A

Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.

3. Which instruction should be emphasized for a client with diabetes being discharged?

Correct answer: B

Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.

4. What is the role of the nurse in the care of a patient with a pressure ulcer?

Correct answer: B

Rationale: The correct answer is B: Assess the wound and reposition the patient frequently. When caring for a patient with a pressure ulcer, it is crucial for the nurse to assess the wound regularly to monitor its progress and prevent complications. Additionally, repositioning the patient frequently helps to relieve pressure on the affected area, prevent further damage, and promote healing. Choice A is incorrect because while cleaning the wound is important, applying a protective dressing is not the primary role of the nurse in managing a pressure ulcer. Choice C is incorrect as applying pressure to the ulcer is harmful, and monitoring for signs of healing should not involve applying pressure. Choice D is incorrect as providing pain relief and administering antibiotics may be necessary but are not the primary interventions for managing a pressure ulcer.

5. A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

Correct answer: D

Rationale: The correct answer is D because a client with pneumonia and a new onset of confusion needs immediate evaluation for changes in neurological status. This could indicate a decline in respiratory status or potential complications such as hypoxia or sepsis. Option A, a client who is NPO and has dry mucous membranes, may need intervention but does not indicate an acute change in condition. Option B, a client with rotavirus who has been vomiting, requires assessment and intervention but does not pose an immediate threat to life. Option C, a client with a urinary catheter and cloudy urine, may indicate a urinary tract infection but does not require immediate attention compared to the client with new onset confusion and pneumonia.

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