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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The correct answers are choices A, C, D, and E:
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Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
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Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
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Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
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Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
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Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.
In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.
Correct Answer is D
Explanation
Choice A rationale:
Beneficence. Beneficence refers to the ethical principle of doing what is best for the client's well-being and promoting their welfare. While returning with pain medication promptly does contribute to the client's well-being, this principle does not specifically address the nurse's commitment to keeping promises or being faithful to their word.
Choice B rationale:
Utility. Utility refers to the ethical principle of seeking the greatest benefit for the greatest number of people. Fulfilling a promise to provide pain medication within the agreed-upon time frame benefits the individual client but is not necessarily related to maximizing overall utility for a broader population.
Choice C rationale:
Justice. Justice involves fairness and equitable distribution of resources and care. While ensuring timely pain relief can be seen as a just action, the concept of justice is not directly tied to keeping promises or fidelity.
Choice D rationale:
Fidelity. Fidelity, also known as "non-maleficence," centers on being faithful to commitments and maintaining trust in the nurse-client relationship. Returning with the medication as promised within 15 minutes exemplifies fidelity, as the nurse is honoring their commitment to the client's well-being and building trust through their actions.
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