Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Heart rate 99 beats/minute

Dark, yellow urine

Urinated 30 mL

Temperature 101° F (38.3° C)

Answer and Explanation

Correct Answer : A,B,C

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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Correct Answer is B, A, C, D

Explanation

1. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.

2. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.

3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.

4. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.

5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently.

A. Administer the medication at least 30 minutes prior to the client's meals. B. Ensure peak and trough serum levels are collected with the third dose of medication. C. Observe the client for development of involuntary movements of the lips and tongue. D. Assess the skin daily for areas of ecchymosis or other signs of bleeding.

Correct Answer is D

Explanation

A. Administering ketorolac does not require specific timing in relation to meals. It can be given with or without food, but the key considerations are related to the drug’s effects rather than meal timing.
B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
D. Assessing the skin daily for signs of bleeding is crucial because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding due to its effects on platelet function and gastrointestinal mucosa.

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Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

Correct Answer is B, A, C, D

Explanation

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

Correct Answer is D

Explanation

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

The practical nurse (PN) is observing a newly hired unlicensed assistive personnel (UAP) bathing a client who has type 2 diabetes mellitus (DM). The UAP places the client's feet in a wash basin filled with warm soapy water to soak. Which action should the PN take?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

A 3-year-old male is being discharged after surgical correction of cryptorchidism. Which postoperative instruction is most important for the practical nurse (PN) to re-emphasize to the parents about the child's activities at home?

The practical nurse (PN) is preparing a client for discharge after a gastric bypass. Prior to discharge, which information should the PN reinforce with the client to prevent dumping syndrome?

Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?