The nurse is caring for a client admitted with vomiting and diarrhea after vacationing. Which of the following nursing interventions are appropriate for this client? (SELECT ALL THAT APPLY)

Monitoring intake and output

Providing good mouth and skin care

Obtaining daily weights

Assessing level of consciousness

Administering a loop diuretic

Answer and Explanation

Correct Answer : A,B,C,D

A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.

B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.

C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.

D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.

E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea

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Correct Answer is ["24"]

Explanation

For a client prescribed 2 grams of amoxicillin/clavulanic acid every 12 hours, and given that the medication is supplied in 500 mg capsules,

The client would need to take four capsules to meet the 2-gram requirement per dose. Since the medication is to be taken every 12 hours, this equates to two doses per day.

For a 3-day business trip, the client would need to take a total of 6 doses. Therefore, the client should take 24 capsules (4 capsules per dose multiplied by 6 doses) with them to ensure they have enough medication for the duration of their trip.

A. plastic insertion spike. B. catheter adapter (hub). C. drip chamber. D. Y-site injection port. E. roller clamp to regulate flow.

Correct Answer is ["A","B","D"]

Explanation

A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.

B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.

D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.

C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.

E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.

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The nurse is caring for a client admitted with vomiting and diarrhea after vacationing. Which of the following nursing interventions are appropriate for this client? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive 2 grams of amoxicillin/clavulanic acid every 12 hours. The medication is supplied in 500 mg capsules. The client confirms with the nurse that they should take how many capsules with them on a 3-day business trip out of town? (Use preceding zeros. Do not use trailing zeros)

Correct Answer is ["24"]

Explanation

The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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