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 A

Explanation

Choice A reason: Washing hands with warm soapy water before sticking the finger is a critical step in the process of self-monitoring blood glucose. Clean hands help prevent infections and ensure that the blood sample is not contaminated, which can affect the accuracy of glucose readings. This practice indicates that the client understands and can effectively follow the proper procedure for SMBG.

Choice B reason: Using a lancing device on the centre of the finger pad is not the correct technique. The sides of the finger pads are recommended for pricking because they are less sensitive than the centre and can provide a better sample with less discomfort. This indicates a misunderstanding of the correct procedure.

Choice C reason: Informing the healthcare provider of average haemoglobin A1C results weekly is unnecessary. Haemoglobin A1C is typically measured every 3 to 6 months to monitor long-term glucose control. Weekly reporting is not required and shows a lack of understanding about the appropriate use of A1C measurements.

Choice D reason: Documenting haemoglobin A1C results from the SMBG monitor every morning is incorrect. The SMBG monitor measures daily blood glucose levels, not haemoglobin A1C. Haemoglobin A1C provides an average blood glucose level over the past 2 to 3 months and is not obtained from daily SMBG readings.

A. Join a group weight loss program. B. Begin a smoking cessation class. C. Consider hormone replacement therapy. D. Schedule rest periods after eating.

Correct Answer is A

Explanation

Choice A reason: Joining a group weight loss program is important for the client's overall health, particularly due to obesity being a significant risk factor for gallbladder disease. Weight loss can help decrease the likelihood of gallstone formation and other gallbladder-related issues. Participation in a weight loss program can also provide support and structured guidance for achieving a healthier weight.

Choice B reason: Beginning a smoking cessation class is beneficial for the client's health, as smoking is a risk factor for many diseases, including gallbladder issues. However, in the context of reducing gallbladder disease risk, weight loss would have a more direct and immediate impact, making it the primary focus for intervention.

Choice C reason: Considering hormone replacement therapy may be relevant for managing symptoms associated with menopause. However, it is not directly related to the risk reduction for gallbladder disease. Hormone replacement therapy should be discussed with a healthcare provider to weigh the benefits and risks.

Choice D reason: Scheduling rest periods after eating is generally helpful for digestion and comfort, but it does not directly address the key risk factors for gallbladder disease in this client, such as obesity and diet. Addressing these primary risk factors through weight loss would be more effective in reducing the client's risk.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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