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 C

Explanation

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

A. One drop od tid. B. One drop ou daily. C. One drop right ear bid. D. One drop left eye daily.

Correct Answer is D

Explanation

One drop left eye daily.

This is because it uses the correct abbreviation for left eye (os) and the correct frequency (daily).

The other choices are wrong because:

Choice A uses od which means right eye, not once daily.

Choice B uses ou which means both eyes, not each eye.

Choice C uses right ear which is not an eye drop medication. Some common eye drop prescription abbreviations are:

gt or gtt for drop or drops
od for right eye
os for left eye
ou for both eyes
bid for twice a day
tid for three times a day
qid for four times a day
prn for as needed

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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