The nurse is assessing a 66-year-old client who reports having a fever and feeling weak and dizzy with nausea and vomiting for three days. The nurse observes a dry tongue and oral mucosa, and concentrated urine. To best assess the client's fluid status, which parameter(s) should the nurse check?

Temperature

BP and pulse in lying, then sitting and standing positions

Pulse oximetry reading on room air

Respiratory rate and depth

Answer and Explanation

The Correct Answer is B

A. Temperature: While temperature assessment is important in evaluating a client's condition, it primarily indicates the presence of fever, which the client already reports. However, it does not provide direct information about the client's fluid status.

B. BP and pulse in lying, then sitting and standing positions: Assessing blood pressure (BP) and pulse in different positions (lying, sitting, and standing) helps evaluate orthostatic changes, which can indicate volume depletion or dehydration. A drop in BP and an increase in pulse rate upon standing suggest volume depletion and orthostatic hypotension, which are indicators of fluid loss.

C. Pulse oximetry reading on room air: Pulse oximetry measures the oxygen saturation of arterial blood and is primarily used to assess respiratory status and oxygenation. While it provides valuable information about oxygen levels, it does not directly assess fluid status.

D. Respiratory rate and depth: Respiratory rate and depth can be affected by various factors, including pain, fever, and respiratory conditions. While changes in respiratory rate and depth can indicate distress or respiratory compromise, they are not specific indicators of fluid status and may not directly reflect hydration status.

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Free Nursing Study Resources

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

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

A. always has a religious connotation. B. is a narrower concept than religion. C. does not necessarily include religion. D. has been created by humans to define ethical conduct.

Correct Answer is C

Explanation

A. always has a religious connotation: This statement is incorrect. While spirituality can be intertwined with religion for many individuals, it does not always have a religious connotation. Spirituality encompasses a broader sense of connection to something greater than oneself, which may or may not be associated with organized religion.

B. is a narrower concept than religion: This statement is incorrect. Spirituality is often considered a broader concept than religion. While religion typically involves organized beliefs, rituals, and practices within a specific faith tradition, spirituality encompasses a wider range of experiences, beliefs, and practices that relate to the search for meaning, purpose, and connection to the transcendent.

C. does not necessarily include religion: This statement is correct. Spirituality can exist independently of religion. While religion often involves spirituality, spirituality can encompass a wide range of beliefs, experiences, and practices that may or may not be connected to organized religion. Individuals can experience spirituality through various means such as nature, relationships, art, meditation, and personal reflection, regardless of religious affiliation.

D. has been created by humans to define ethical conduct: This statement is incorrect. Spirituality is not solely created by humans to define ethical conduct. While ethical principles and values may be part of spiritual beliefs for many individuals, spirituality encompasses broader aspects of human experience, including the search for meaning, connection, and transcendence, which extend beyond ethical conduct.

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The nurse is assessing a 66-year-old client who reports having a fever and feeling weak and dizzy with nausea and vomiting for three days. The nurse observes a dry tongue and oral mucosa, and concentrated urine. To best assess the client's fluid status, which parameter(s) should the nurse check?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

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

Explanation

The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

Correct Answer is C

Explanation

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