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: Upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease (PUD). This type of pain is typically located in the epigastric region and is often relieved by eating or taking antacids, which aligns with the presentation of PUD.

Choice B reason: Marked loss of weight and appetite over the last 3 or 4 months can occur in various gastrointestinal conditions, but it is not specific enough to support a diagnosis of PUD. This symptom alone does not provide enough evidence for PUD.

Choice C reason: Severe abdominal cramps and diarrhea after eating spicy foods might indicate irritable bowel syndrome (IBS) or another gastrointestinal condition. These symptoms are not typically associated with PUD.

Choice D reason: Frequent use of chewable and liquid antacids for indigestion can indicate chronic gastrointestinal discomfort, but it does not specifically point to PUD. It suggests ongoing gastric issues but lacks specificity for diagnosing PUD.

A. Review the client's fluid intake prior to bedtime. B. Obtain a fingerstick blood glucose level. C. Collect a urine specimen for culture analysis. D. Palpate the bladder above the symphysis pubis.

Correct Answer is D

Explanation

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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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

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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