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A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)

Amber/dark colored urine

Weak, thready pulse

Distended neck veins

Bradycardia

Decreased capillary refill

Answer and Explanation

Correct Answer : A,B,E

A. Amber or dark-colored urine is a sign of dehydration and indicates a decrease in fluid volume.

B. A weak, thready pulse is often seen in clients with hypovolemia due to reduced circulating blood volume.

C. Distended neck veins are a sign of fluid overload, not hypovolemia.

D. Bradycardia is typically not associated with hypovolemia; tachycardia is more common.

E. Decreased capillary refill is indicative of reduced perfusion, a symptom of hypovolemia.

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Correct Answer is ["675"]

Explanation

To calculate the dosage of vancomycin, first convert the client's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The client weighs 198 pounds, which is approximately 90 kilograms (198 ÷ 2.2). The prescribed dose is 15 mg/kg/day, so for a 90 kg individual, this would be 1350 mg/day (90 kg × 15 mg/kg). Since the dosage is divided equally every 12 hours, the nurse would administer half of the daily dosage per dose, resulting in 675 mg every 12 hours (1350 mg/day ÷ 2). Therefore, the nurse should administer 675 mg with each dose.

A. Reposition the client every 2 hours. B. Apply compression stockings. C. Ambulate the client at least once per shift. D. Perform hourly skin checks.

Correct Answer is A

Explanation

A. Repositioning every 2 hours is a standard intervention to prevent pressure ulcers and promote circulation.

B. Compression stockings are used for preventing DVTs but do not directly prevent skin breakdown.

C. Ambulation is not feasible for a quadriplegic client.

D. Hourly skin checks can be beneficial but are secondary to preventive measures like repositioning.

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A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["675"]

Explanation

In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?

Correct Answer is A

Explanation

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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While completing a comprehensive assessment of a client who is admitted with chronic obstructive pulmonary disorder, the objective data revealed the client's nails appear convexed and wide with an angle greater than 160 degrees. How would the nurse document this finding?

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The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

A nurse is assessing for cyanosis in a client who has dark skin. Which part of the body should the nurse examine to identify cyanosis in this client?

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?