The nurse is caring for a newly admitted client suspected of having bacterial gastroenteritis with frequent watery diarrhea for several days and has been unable to hold down fluids. All of the following are ordered for the client. What is the priority intervention?

Apply zinc ointment to perianal area for excoriation

Administer probiotics one capsule by mouth three times a day

Obtain a stool specimen for culture

Administer intravenous fluids at 125 mL per hour

Answer and Explanation

The Correct Answer is D

A. Zinc ointment is appropriate to protect skin from breakdown due to diarrhea, but it does not address the client’s most urgent physiologic need.
B. Probiotics may support gut health, but oral administration is not appropriate when the client cannot hold down fluids and is at risk for dehydration.
C. Obtaining a stool specimen is important for identifying the infectious cause, but it is not the immediate priority.
D. The client has had several days of diarrhea and is unable to tolerate oral fluids, placing them at high risk for severe dehydration and electrolyte imbalance. Administering IV fluids at 125 mL/hr is the priority intervention to restore fluid balance and prevent hypovolemic shock.

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Correct Answer is A

Explanation

A. A weight gain of 3 pounds in 24 hours indicates fluid retention, which can quickly progress to fluid overload, pulmonary edema, and heart failure. This is the priority finding to report.
B. Decreased muscle strength may occur due to electrolyte imbalance or fatigue but is not immediately life-threatening.
C. An elevated BUN is expected in chronic kidney disease and is not as urgent as acute fluid retention.
D. Bilateral 2+ pedal pulses are normal and do not require reporting.

A. The hip has dislocated B. The incision has dehisced C. There is bleeding at the operative site D. An infection has developed suddenly

Correct Answer is A

Explanation

A. A sudden onset of severe hip pain with observable shortening and external rotation of the affected extremity is a hallmark sign of hip dislocation, a serious complication after hip replacement surgery. This requires immediate intervention to prevent neurovascular damage.
B. Incision dehiscence involves the surgical wound opening but does not typically cause leg shortening or severe sudden hip pain.
C. Bleeding at the operative site may lead to swelling, bruising, or decreased hemoglobin, but it does not cause limb shortening or abrupt severe pain localized to the hip joint.
D. Infection usually develops gradually with fever, redness, warmth, or drainage at the surgical site, not a sudden severe pain with extremity shortening.

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The nurse is caring for a newly admitted client suspected of having bacterial gastroenteritis with frequent watery diarrhea for several days and has been unable to hold down fluids. All of the following are ordered for the client. What is the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with chronic kidney disease. Which assessment finding is the priority for the nurse to report?

Correct Answer is A

Explanation

The nurse is caring for a client who had a left total hip replacement three days ago. The client suddenly has severe left hip pain and the nurse notes a shortening of the left lower extremity. What complication does the nurse suspect?

Correct Answer is A

Explanation

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