The nurse is assessing the client's intake and output values for the shift (see chart below).
Intake for the shift
250mL Water
120mL Coffee
500mL Intravenous fluid
135 mL Orange Juice
120 mL Ice Cream
120 mL Jello
Output for the shift
545mL Urine
53mL Wound Drainage
200mL Emesis
375mL Urine
200mL Urine
75mL Loose Stool
480mL Urine
Based on these intake and output findings, what is the priority assessment by the nurse?
Palpate for pitting edema.
Assess for oral temperature.
Inspect the oral mucosa.
Auscultate adventitious lung sounds.
The Correct Answer is C
A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Air being diverted from the trachea to the bronchi does not explain the cause of a wheeze. This is a normal part of airflow distribution.
B. Air passing through constricted passageways is correct. A wheeze is a high-pitched, musical sound that occurs when air flows through narrowed or obstructed airways, as seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
C. Air increasing in turbulence in a wide passage is incorrect. Wheezing occurs due to airway narrowing, not widening.
D. Air leaking from the alveoli into the pleural space describes pneumothorax, which presents with absent breath sounds rather than wheezing.
Correct Answer is B
Explanation
A. Increased urinary output is incorrect because NSAIDs like ibuprofen can cause kidney damage, leading to fluid retention and decreased urine output, not increased output.
B. Increased heart rate is correct. Long-term NSAID use can cause gastrointestinal (GI) irritation and ulcers, which may lead to occult blood loss and anemia. Anemia can result in tachycardia (increased heart rate) as the body compensates for decreased oxygen delivery. C. Decreased heart rate is incorrect because anemia and pain typically cause tachycardia, not bradycardia.
D. Hypoglycemia is incorrect because NSAIDs do not significantly impact blood glucose levels.
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