The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Administering diuretics as ordered

Providing good skin and mouth care

Monitoring intake and output

Obtaining daily weights

Answer and Explanation

Correct Answer : B,C,D

A. Administering diuretics as ordered: This option is not appropriate for dehydration management. Diuretics are medications that increase urine output and are typically used to treat fluid overload rather than dehydration. Administering diuretics to a dehydrated client could exacerbate fluid loss and worsen the condition.

B. Providing good skin and mouth care: This is a suitable intervention for managing dehydration. Dehydration can lead to dry skin and mucous membranes. Providing good skin care, including moisturizing, can help prevent skin breakdown. Additionally, ensuring adequate oral hygiene and providing moist mouth swabs can alleviate discomfort associated with dry mouth.

C. Monitoring intake and output: This is an essential nursing intervention for managing dehydration. Monitoring the client's fluid intake and output allows the nurse to assess the balance between fluid intake and loss. Decreased urine output is a common sign of dehydration, while monitoring intake helps ensure the client is receiving adequate fluids.

D. Obtaining daily weights: This is an appropriate nursing intervention for managing dehydration. Daily weights can help assess changes in fluid balance. A sudden increase in weight may indicate fluid retention, while a decrease may indicate ongoing fluid loss, both of which are important to monitor in dehydration.

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Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

A. polyuria. B. retention. C. oliguria. D. anuria.

Correct Answer is C

Explanation

A. Polyuria: Polyuria refers to abnormally large volume of urine output, typically exceeding 2.5 to 3 liters per day in adults. It is often associated with conditions such as diabetes mellitus, diabetes insipidus, or certain medications that increase urine production. Urinating 250 mL over 24 hours does not meet the criteria for polyuria.

B. Retention: Urinary retention refers to the inability to completely empty the bladder, leading to accumulation of urine. It is characterized by difficulty initiating urination or incomplete bladder emptying. Urinating 250 mL over 24 hours does not indicate urinary retention.

C. Oliguria: Oliguria is defined as diminished urine output, typically less than 400 mL per day in adults. It is a common sign of kidney dysfunction or acute kidney injury. Urinating 250 mL over 24 hours falls within the range of oliguria, indicating decreased urine production compared to normal.

D. Anuria: Anuria is the absence of urine production or excretion, typically defined as urine output less than 100 mL per day. It is often indicative of severe kidney dysfunction, renal failure, or obstruction of the urinary tract. While the client's urine output of 250 mL over 24 hours is low, it does not meet the criteria for anuria.

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The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

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Explanation

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