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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

A. Collect client data in order to make a professional clinical judgment of the client's overall level of functioning. B. Provides information about chronic diseases and medications to identify how a present illness is impacting the client. C. Compile data during a step-by-step physical examination. D. Focuses on the client's physiologic status in order to implement provider decisions.

Correct Answer is A

Explanation

A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

What is the primary purpose of a nursing health assessment?

Correct Answer is A

Explanation

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