The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin and hematocrit level.

Consult with dietitian to determine patient's nutritional needs.

Encourage patient to prepare simple meals or to obtain assistance with meal preparation if possible.

Encourage patient to eat meals with visitors or others when possible.

Answer and Explanation

The Correct Answer is C

A. Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin, and hematocrit level: This option focuses on assessing the patient's nutritional status, which is important for planning appropriate interventions. However, in a patient presenting with severe diarrhea and vomiting, the priority is to address immediate physiological needs and stabilize the patient's condition before conducting comprehensive assessments. While assessing nutritional status is important for long-term management, it is not the first action the nurse should take in this acute situation.

B. Consult with a dietitian to determine the patient's nutritional needs: Consulting with a dietitian is an important step in addressing the patient's nutritional needs, especially in cases of prolonged diarrhea and vomiting. However, in this scenario, the patient is experiencing severe symptoms that require immediate attention. Before consulting with a dietitian, the nurse should address the patient's acute symptoms and initiate interventions to manage fluid and electrolyte imbalances.

C. Encourage the patient to prepare simple meals or to obtain assistance with meal preparation if possible: This option addresses the immediate need to provide nutritional support to the patient. Encouraging the patient to consume simple, easily digestible meals or to seek assistance with meal preparation helps ensure that the patient receives adequate nutrition despite experiencing symptoms of diarrhea and vomiting. Providing practical advice on meal preparation empowers the patient to take control of their nutritional intake, which can be beneficial in managing symptoms and promoting recovery.

D. Encourage the patient to eat meals with visitors or others when possible: While social support and companionship can have a positive impact on the patient's overall well-being, including their nutritional intake, this option is not the first priority in this scenario. The patient's severe symptoms of diarrhea and vomiting require immediate attention to address fluid and electrolyte imbalances and prevent complications such as dehydration. Once the patient's condition stabilizes, encouraging social interaction during meals can be beneficial for promoting nutritional intake and emotional support.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Superficial ulcers in the calves: Chronic venous insufficiency can lead to poor circulation in the lower legs, causing tissue damage and the development of superficial ulcers, typically located around the ankles or calves.

B. Dilatation of superficial veins: One of the hallmark signs of chronic venous insufficiency is the visible dilatation (enlargement) of superficial veins, often seen as varicose veins, due to the impaired return of blood to the heart.

C. Shiny skin: Chronic venous insufficiency can cause changes in the skin texture, including thinning and a shiny appearance. This occurs due to chronic edema and impaired circulation in the affected area.

D. Blackened toes: Blackened toes are not typically associated with chronic venous insufficiency. This symptom is more commonly seen in conditions such as peripheral artery disease (PAD) or severe ischemia.

E. Dependent rubor: Dependent rubor, characterized by reddish-blue discoloration of the lower extremities when in a dependent position (e.g., hanging off the bed), can occur in chronic venous insufficiency due to impaired venous return and pooling of blood in the lower extremities.

Correct Answer is ["200"]

Explanation

Infusion rate (mL/hr) = 100/30 × 60

Infusion rate (mL/hr) = 100/30 × 60 = 200

Therefore, the nurse should set the IV pump to deliver 200 mL/hr.

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The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient diagnosed with chronic venous insufficiency. Which clinical manifestations are consistent with this diagnosis? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is ["200"]

Explanation

The nurse is applying standard precautions in the care of a patient who has a history of human immunodeficiency virus. What key element of standard precaution?

A nurse is developing a discharge teaching plan for a patient diagnosed with peripheral arterial disease. Which instruction will the nurse include in the plan?

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