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A nurse in the urgent care facility is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which objective findings should the nurse expect? (Select three options that apply.)

Pale yellow urine

Flat neck veins

Hypotension

Poor skin turgor

Bradycardia

Answer and Explanation

Correct Answer : B,C,D

A. Pale yellow urine would not be expected, as dehydration often leads to concentrated, dark urine.

B. Flat neck veins are a sign of dehydration and decreased fluid volume.

C. Hypotension is expected with dehydration due to a drop in circulating blood volume.

D. Poor skin turgor is a common indicator of dehydration as the skin loses elasticity.

E. Bradycardia is not expected; rather, tachycardia is more common in dehydration as the body tries to compensate for fluid loss.

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Correct Answer is B

Explanation

A. Having the client place a plastic bag over their head is dangerous and should never be done.

B. Teaching breathing techniques, such as diaphragmatic breathing or using a paper bag, helps the client retain more carbon dioxide and can prevent respiratory alkalosis.

C. Positioning the client in a high-Fowler position may be helpful for breathing but does not address hyperventilation or respiratory alkalosis directly.

D. While encouraging the client to remain calm may help, it is not as effective as teaching specific breathing techniques.

A. Patient B. Patient's roommate C. Certified Nursing Assistant (CNA) D. Nurse

Correct Answer is A

Explanation

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

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A nurse in the urgent care facility is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which objective findings should the nurse expect? (Select three options that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

Correct Answer is B

Explanation

When collecting data, the nurse understands which individual is the primary source of information regarding pain tolerance.

Correct Answer is A

Explanation

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