A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority?

Auscultate the client's bowel sounds.

Measure the client's temperature.

Check the client's urine specific gravity.

Obtain the client's serum potassium level.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice B rationale:

“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.

Choice C rationale:

“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice D rationale:

“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.

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Correct Answer is C

Explanation

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

A. Interpreter. B. Social worker. C. Occupational therapist. D. Spiritual advisor.

Correct Answer is A

Explanation

Choice A rationale:

Since the client speaks a different language than the nurse, involving an interpreter is crucial to ensure effective communication during the preoperative teaching. This will help the client fully understand the procedure, potential risks, and postoperative care instructions.

Choice B rationale:

A social worker primarily addresses psychosocial needs and resources. While they play an important role, their involvement wouldn't directly address the language barrier during the preoperative teaching.

Choice C rationale:

An occupational therapist assists with physical function and daily activities. While they might be involved postoperatively, their role is not as crucial for overcoming the language barrier during preoperative teaching.

Choice D rationale:

A spiritual advisor provides support based on religious or spiritual beliefs. While emotional and spiritual support are important, their involvement in this scenario doesn't address the language barrier and the need for accurate information during preoperative teaching.

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A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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