A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake.

Slow the normal saline to a keep open rate while contacting the healthcare provider.

Review the client's medications to see if the client can be given a PRN diuretic.

Instruct the client to withhold oral fluids and report the symptoms to the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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Correct Answer is C

Explanation

Choice A reason: Keeping toenails trimmed short is important for foot care, especially in clients with PAD, but it is not the highest priority.

Choice B reason: Applying a heating pad to soothe leg pain can provide temporary relief but does not address the underlying issue of PAD or reduce cardiovascular risk.

Choice C reason: Enrolling in a smoking cessation program is the highest priority. Smoking significantly exacerbates PAD and increases the risk of further cardiovascular events, including heart attacks. Quitting smoking is crucial for improving vascular health and reducing the risk of complications.

Choice D reason: Reducing intake of high saturated fats and salt is important for overall cardiovascular health but is not as immediate or impactful as smoking cessation in reducing the risk of complications from PAD and MI.

A. Take a walk with the client. B. Sit the client in a recliner. C. Administer a sleeping medication. D. Move the client to a locked unit.

Correct Answer is A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

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A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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