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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.
It also allows the nurse to correct any misunderstandings and reinforce key points.
Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.
Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.
Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.
Correct Answer is D
Explanation
The question asks how many milligrams of the medication will be in 1 mL of D5W. To find this, we need to know the concentration of the medication in the solution.
Concentration is the amount of medication per unit volume of solution. We can use this formula:
Concentration = Mass / Volume
We know that 250 mg of the medication is diluted in 500 mL of D5W. So we can plug these values into the formula:
Concentration = 250 mg / 500 mL Simplifying, we get:
Concentration = 0.5 mg / mL
This means that there are 0.5 mg of the medication in every 1 mL of D5W. So the answer is
- To check our answer, we can use another formula:
Mass = Concentration x Volume
If we want to find the mass of the medication in 1 mL of D5W, we can multiply the concentration by the volume:
Mass = 0.5 mg / mL x 1 mL Simplifying, we get:
Mass = 0.5 mg
This matches our answer.
The other choices are wrong because they do not use the correct formula or values. Here is why:
Choice A is wrong because it uses the inverse of the concentration (1 / 0.5) instead of the concentration (0.5).
Choice B is wrong because it uses the mass of the medication (250 mg) instead of the concentration (0.5 mg / mL).
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