The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Inspection of lips and mucous membranes.

Pinches the skin on back of the hand.

Measures pulse and blood pressure.

Obtains client's daily weight.

Palpates scalp and hair distribution.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answers are Choices A, B, C, and D.Choice A rationale: Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale: Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale: Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale: Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale: Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.

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Correct Answer is D

Explanation

Insulin regular (Humulin-R) is the only form of insulin that is safe for intravenous administration. This is because it is a short-acting insulin that has a rapid onset and peak time, and does not contain any additives or suspensions that could interfere with the infusion.

Choice A is wrong because insulin aspart (Novo Log) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

Choice B is wrong because insulin glargine (Lantus) is a long-acting insulin that covers insulin needs for about a full day. It is not suitable for intravenous use because it forms micro-precipitates under the skin that release insulin slowly and steadily.

Choice C is wrong because insulin lispro (Humalog) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

A. Maintain trust and avoid behaviors that may increase agitation. B. Order the client to go to their room & alert security. C. Tell the client to sit down or risk isolation and loss of privileges. D. Sedate the client after collecting a lithium level.

Correct Answer is A

Explanation

Maintain trust and avoid behaviors that may increase agitation. This is the priority action because it is important for the nurse to attempt to de-escalate the client and maintain trust.

A. Ordering the client to go to their room and alerting security is not the priority action because it may increase agitation and does not maintain trust.

C. Telling the client to sit down or risk isolation and loss of privileges is not the priority action because it may increase agitation and does not maintain trust.

D. Sedating the client after collecting a lithium level is not the priority action because it does not address the immediate need to de-escalate the situation and maintain trust.

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The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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