A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Tenting

Protruding eyeballs

Elevated blood pressure

Dry mucous membranes

Answer and Explanation

The Correct Answer is A

A. Tenting

Tenting refers to the delayed recoil of the skin when pinched. In a dehydrated state, the skin loses elasticity, leading to tenting due to decreased skin turgor. This is a specific sign of fluid-volume deficit.

B. Protruding eyeballs

Protruding eyeballs are not typically associated with dehydration. This could be related to other conditions such as thyroid dysfunction, but it is not a specific indicator of fluid-volume deficit.

C. Elevated blood pressure

Elevated blood pressure is not a typical sign of dehydration. In fact, dehydration often leads to a decrease in blood pressure due to reduced blood volume.

D. Dry mucous membranes

Dry mucous membranes can be an indication of dehydration, but in the context of the question, tenting (Option A) is a more specific sign related to skin turgor and is commonly assessed when evaluating for dehydration.

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Correct Answer is C

Explanation

A. Skeletal traction

Skeletal traction involves the use of pins or wires that are surgically inserted directly into the bone. It is a more invasive form of traction commonly used during or after surgery. Skeletal traction provides a strong and direct pull on the bones, allowing for better alignment and immobilization.

B. Pelvic sling

A pelvic sling is not a specific type of traction. It may refer to a supportive device or garment that helps stabilize the pelvis. While it can provide support, it does not apply the same type of traction force as Buck's traction or skeletal traction.

C. Buck’s traction

Buck's traction is a type of skin traction commonly used as a temporary measure to immobilize and align fractured bones, particularly in the lower extremities. It involves the application of a boot or a splint to the affected leg, with traction applied through a system of weights and pulleys. Buck's traction is often used before hip surgery.

D. Russell’s traction

Russell's traction involves the application of traction to the lower leg using a splint and bandages. It is often used for fractures of the femur. While it is a form of traction, it is not commonly used for hip fractures.

A. Offer to request a prescription for an indwelling urinary catheter. B. Keep a night light on in the client’s room. C. Limit the client’s fluid intake in the evening. D. Put the side rails up and tell the client to call for assistance to the bathroom.

Correct Answer is B

Explanation

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.

B. Keep a night light on in the client’s room.

This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.

C. Limit the client’s fluid intake in the evening.

Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.

D. Put the side rails up and tell the client to call for assistance to the bathroom.

While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.

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A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a fracture of the right hip. Which of the following types of traction should the nurse expect the client to have prior to hip surgery?

Correct Answer is C

Explanation

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, “I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings.” Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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