The nurse is caring for a client who received a new diet prescription from the physician for nothing by mouth (NPO) except ice chips.
Which actions would the nurse take to alleviate the effects of dehydration? Select all that apply
Observe mucous membranes for dryness
Provide frequent oral care with moist swabs
Offer the client small sips of water
Increase the rate of intravenous (IV) fluids
Correct Answer : A,B,D
Choice A rationale
Observing mucous membranes for dryness can indicate dehydration.
Choice B rationale
Providing frequent oral care with moist swabs can help alleviate the discomfort of a dry mouth due to NPO status.
Choice C rationale
Offering the client small sips of water is not appropriate as the client is on a diet of nothing by mouth (NPO) except ice chips.
Choice D rationale
Increasing the rate of intravenous (IV) fluids can help prevent dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Absence of bowel sounds can be a normal finding post-operatively and is not necessarily a cause for concern.
Choice B rationale
A small amount of bloody drainage on the dressing is not uncommon after surgery and is not typically a cause for concern.
Choice C rationale
A rigid abdomen on palpation is a concerning finding after an appendectomy. It could indicate peritonitis, a serious infection of the abdominal cavity that can occur if the appendix burst before or during surgery.
Choice D rationale
Pain at the operative site is expected after an appendectomy. However, severe or increasing pain could indicate a complication and should be evaluated by a healthcare provider.
Correct Answer is B
Explanation
Choice A rationale
While intestinal obstruction can occur after any abdominal surgery, it is not the most common complication following ileostomy creation.
Choice B rationale
Fluid and electrolyte imbalance is a common complication following ileostomy surgery. This is due to the fact that the ileum, which is now rerouted to an external opening in the abdominal wall, is responsible for absorbing a significant amount of fluid and electrolytes. When it is diverted, these substances can be lost, leading to imbalances.
Choice C rationale
Malabsorption of fat is not typically a primary concern following ileostomy surgery. While malabsorption can occur in diseases affecting the ileum, it is not a direct result of the surgery itself.
Choice D rationale
Folate deficiency is not a common complication following ileostomy surgery. The terminal ileum, which is typically used to create the ileostomy, is primarily responsible for the absorption of vitamin B12, not folate.
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