A client with a 4-day history of diarrhea from a foodborne illness is receiving IV fluids for dehydration. Which finding indicates the client's dehydration is improving?

The client's mucous membranes are moist.

The client's urine is dark and concentrated.

The client's capillary refill is 4 seconds.

The client's skin is tenting at the collar bone.

Answer and Explanation

The Correct Answer is A

Rationale:

A. The client’s mucous membranes are moist indicates improvement in hydration status. Dry mucous membranes are a classic sign of dehydration. When IV fluids are effective, moisture returns to the oral mucosa, reflecting improved circulating volume and tissue hydration. This is a positive sign that treatment is working.

B. Dark, concentrated urine indicates ongoing dehydration. When fluid volume is low, the kidneys conserve water, resulting in decreased urine output and darker, more concentrated urine. Improvement would be reflected by lighter-colored urine and adequate output.

C. A capillary refill time of 4 seconds is abnormal and suggests poor peripheral perfusion, which is commonly seen in dehydration. Normal capillary refill is typically less than 2 seconds. Delayed refill indicates dehydration is not yet corrected.

D. Skin tenting at the collarbone indicates decreased skin turgor, a sign of dehydration. Improvement would be demonstrated by skin returning quickly to its normal position after being pinched.

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Correct Answer is ["A","C","D","E"]

Explanation

Rationale:

A. Keeping suction equipment at the bedside is appropriate. Clients on aspiration precautions are at risk for inhaling food, liquids, or secretions into the airway. Having suction readily available ensures rapid intervention if choking or aspiration occurs, promoting airway safety.

B. Suggesting the client use a straw to drink liquids is not appropriate. Using a straw can increase the speed and volume of liquid entering the mouth, which may raise the risk of aspiration in clients with swallowing difficulties. Therefore, this action should not be included in the plan of care unless specifically ordered by a speech-language pathologist.

C. Encouraging slow, small bites is correct. Small bites reduce the risk of choking and allow the client more time to chew and swallow safely. This helps minimize the risk of aspiration and improves swallowing control.

D. Remaining with the client during meals is appropriate. Close supervision allows the nurse to monitor swallowing ability, ensure proper positioning, and intervene quickly if signs of aspiration occur.

E. Monitoring for coughing while eating is correct. Coughing, choking, throat clearing, or a wet voice during meals are signs of possible aspiration. Early recognition allows for prompt intervention and prevention of complications such as aspiration pneumonia.

A. "I will alternate cheeks with each dose to avoid irritation." B. "I should chew the medication before placing it in my cheek." C. "I need to swallow the medication immediately after taking it." D. "I should place the medication under my tongue to dissolve."

Correct Answer is A

Explanation

Rationale:
A. "I will alternate cheeks with each dose to avoid irritation" indicates effective learning. Buccal medications are placed between the cheek and gum to allow absorption through the mucous membrane. Alternating cheeks with each dose helps prevent local irritation and promotes even absorption.

B. "I should chew the medication before placing it in my cheek" is incorrect. Buccal medications are meant to dissolve slowly in the mouth without chewing. Chewing can destroy the medication’s intended delivery mechanism and reduce effectiveness.

C. "I need to swallow the medication immediately after taking it" is incorrect. Buccal medications are designed to be absorbed through the oral mucosa and should not be swallowed immediately, as swallowing may reduce the medication’s efficacy.

D. "I should place the medication under my tongue to dissolve" is incorrect. Placing the medication under the tongue is the administration method for sublingual medications, not buccal medications. Buccal medications are specifically placed between the cheek and gum.

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A client with a 4-day history of diarrhea from a foodborne illness is receiving IV fluids for dehydration. Which finding indicates the client's dehydration is improving?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client with a new order for aspiration precautions. What action(s) should the nurse incorporate into the client's plan of care? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse provides education to a client on buccal medication. Which statement by the client indicates effective learning?

Correct Answer is A

Explanation

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