The nurse notices that an older adult’s urine is concentrated. Which step should the nurse implement next?
Evaluate the medication list
Review laboratory reports
Increase oral fluid intake
Determine fluid volume status
The Correct Answer is D
Choice A reason: Evaluating the medication list is a possible step that the nurse can take, as some medications can affect urine concentration or cause dehydration. However, it is not the first step that the nurse should implement, as it does not address the immediate problem of fluid balance.
Choice B reason: Reviewing laboratory reports is another possible step that the nurse can take, as some laboratory tests can indicate the level of hydration or kidney function of the patient. However, it is not the first step that the nurse should implement, as it does not provide a direct assessment of fluid status.
Choice C reason: Increasing oral fluid intake is a potential intervention that the nurse can suggest, as it can help to dilute the urine and prevent dehydration. However, it is not the first step that the nurse should implement, as it may not be appropriate for some patients who have fluid restrictions or other medical conditions.
Choice D reason: Determining fluid volume status is the first step that the nurse should implement, as it can help to identify the cause and severity of urine concentration and guide further actions. The nurse can assess the patient's fluid intake and output, weight, blood pressure, pulse, skin turgor, mucous membranes, and urine specific gravity to determine fluid volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Overhydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess fluid volume, which can cause medical complications, such as edema, hyponatremia, or heart failure.
Choice B reason: Dehydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has insufficient fluid volume, which can cause medical complications, such as hypotension, tachycardia, or kidney failure.
Choice C reason: Hypernatremia is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess sodium concentration in the blood, which can cause medical complications, such as thirst, confusion, or seizures.
Choice D reason: Hydration is the definition of the promotion of an adequate fluid balance, as it refers to the maintenance of the optimal amount and distribution of fluid in the body, which can prevent medical complications, such as dehydration, electrolyte imbalance, or infection.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Physical status is an important assessment for post-fall prevention, as it can identify the possible causes and consequences of the fall, such as injuries, pain, mobility, balance, strength, vision, hearing, cognition, and medication use. Physical status can also help determine the appropriate interventions and referrals for the older adult, such as physical therapy, occupational therapy, or home health care.
Choice B reason: Financial status is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, financial status may influence the older adult's access to health care, social support, and assistive devices, which may affect their recovery and quality of life. Financial status may also be a source of stress or anxiety for the older adult, which may impair their mental and emotional well-being.
Choice C reason: Occupational history is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, occupational history may provide some information about the older adult's past and current activities, skills, and interests, which may help tailor the interventions and goals for the older adult. Occupational history may also reflect the older adult's sense of identity, purpose, and satisfaction, which may affect their motivation and engagement.
Choice D reason: Environment is an important assessment for post-fall prevention, as it can identify the potential hazards and barriers that may contribute to the fall, such as poor lighting, slippery floors, clutter, loose rugs, stairs, or furniture. Environment can also help determine the appropriate modifications and adaptations that can reduce the risk of future falls, such as installing grab bars, handrails, ramps, or alarms. Environment can also influence the older adult's comfort, safety, and independence at home or in other settings.
Choice E reason: None of the above is not the correct answer, as there are two choices that are essential assessments for post-fall prevention.
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