A nurse is caring for an older adult client who has confusion and weakness.
The client has an elevated hematocrit (Hct) of 53%, an elevated blood urea nitrogen (BUN) of 25 mg/dL, and an elevated urine specific gravity of 1.032.Which of the following actions should the nurse contribute to the client's plan of care? (Select all that apply).
Monitor the client's intake and output.
Check the client's orientation to person, place, and time regularly.
Restrict the client's fluid intake.
Instruct the client to sit on the side of the bed for a few minutes before standing.
Weigh the client daily.
Correct Answer : A,B,D,E
Choice A rationale
An elevated Hct (normal ≈ 36%-50%), elevated BUN (normal 8-20 mg/dL), and high urine specific gravity (normal 1.005-1.030) are all indicative of volume depletion or dehydration. Monitoring intake and output precisely quantifies the fluid balance, which is crucial for determining the degree of deficit and evaluating the effectiveness of rehydration therapy.
Choice B rationale
The client's confusion and weakness are potential symptoms of dehydration, as reduced intravascular volume can impair cerebral perfusion and electrolyte imbalances can disrupt nerve and muscle function. Regularly checking orientation provides an essential ongoing assessment of the client's neurological status and the effectiveness of fluid replacement.
Choice C rationale
The client's lab values and symptoms strongly suggest dehydration, which requires increased fluid intake, not restriction. Fluid restriction would exacerbate the existing hypovolemia, further worsening the elevated Hct, BUN, and specific gravity, potentially leading to renal compromise and worsening confusion.
Choice D rationale
Dehydration often leads to orthostatic hypotension due to reduced circulating blood volume. Instructing the client to sit briefly before standing allows time for baroreceptor reflexes to compensate for the positional change, preventing a sudden drop in blood pressure and minimizing the risk of a fall.
Choice E rationale
Daily weights provide a highly sensitive and objective measure of fluid status changes. A rapid change in body weight, especially in the context of dehydration and hypovolemia, directly reflects the magnitude of fluid loss or gain, making it a critical parameter for monitoring the effectiveness of interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The recommended first-line treatment for uncomplicated gonorrhea is typically a single 500 mg intramuscular (IM) injection of Ceftriaxone, a third-generation cephalosporin. This regimen is highly effective because Ceftriaxone achieves high, sustained serum and tissue levels and addresses the increasing rates of antimicrobial resistance seen in Neisseria gonorrhoeae, providing a reliable, single-dose cure to both the client and their partner.
Choice B rationale
Doxycycline is primarily used to treat Chlamydia trachomatis infection, which frequently co-occurs with gonorrhea. While it may be administered alongside Ceftriaxone for dual coverage if chlamydia hasn't been ruled out, it is not the monotherapy for gonorrhea, which requires the higher efficacy of a cephalosporin like Ceftriaxone due to resistance patterns.
Choice C rationale
Penicillin is no longer the standard treatment for gonorrhea because Neisseria gonorrhoeae has developed widespread resistance to penicillins and many other older antibiotics through plasmid-mediated β-lactamase production and chromosomal mutations. Using a single dose of Penicillin would likely result in treatment failure and the progression of the infection, thus necessitating the use of the more potent Ceftriaxone.
Choice D rationale
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae and is a serious sexually transmitted infection (STI) that requires prompt antibiotic treatment. It does not typically resolve on its own. Untreated infection can lead to severe complications, including pelvic inflammatory disease (PID) in women, epididymitis in men, and potentially disseminated gonococcal infection (DGI), highlighting the necessity of effective treatment.
Correct Answer is B
Explanation
Choice A rationale
Monitoring the White Blood Cell (WBC) count is primarily a measure for detecting and tracking infection (normal range 4,500–11,000 cells/mm) or inflammatory processes, not a direct preventative action for deep vein thrombophlebitis (DVT). While inflammation can contribute to hypercoagulability, this action doesn't mechanically or chemically prevent venous stasis or hypercoagulability, the Virchow's triad components.
Choice B rationale
Encouraging increased fluid intake helps to maintain adequate intravascular volume and reduce blood viscosity. Hemoconcentration, resulting from dehydration, increases the concentration of clotting factors and blood cells, making the blood more viscous and sluggish, thus promoting venous stasis and increasing the risk of DVT formation.
Choice C rationale
Keeping the affected knee flexed can compress the popliteal vein, a major deep vein, especially when maintained for prolonged periods post-operatively. This compression promotes venous stasis distal to the flexion point, which is a critical component of Virchow's triad and significantly increases the risk for deep vein thrombophlebitis development.
Choice D rationale
Prolonged bed rest, especially beyond 24-48 hours without prophylactic measures, dramatically reduces the activity of the skeletal muscle pump in the lower extremities. This lack of muscle contraction and relaxation greatly impairs venous return to the heart, leading to severe venous stasis and a high risk of deep vein thrombophlebitis.
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