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 B
Explanation
Choice A: The use of restraints on older patients helps prevent injuries from falls - This statement is not true. The use of restraints can increase the risk of injury and is generally discouraged¹.
Choice B: About 50% to 70% of falls in hospitals occur while transferring between bed and chair - This statement is true. Transfers are a high-risk activity for falls, and appropriate precautions should be taken¹.
Choice C: Falls that do not cause physical injury are not significant - This statement is not true. Even falls without injury can have significant psychological impacts, leading to fear of falling and reduced mobility¹.
Choice D: The get-up-and-go test provides a measure of a patient's energy and initiative - This statement is not true. The get-up-and-go test is used to assess a person's mobility and balance, not their energy and initiative¹.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Grab bars in place are important for preventing falls, as they provide support and stability for the patient when moving around the room, especially in the bathroom. Grab bars can help the patient maintain their balance and avoid slipping or tripping.
Choice B reason: Appropriate footwear is important for preventing falls, as it can reduce the risk of slipping, sliding, or stumbling. Appropriate footwear should fit well, have non-skid soles, and be comfortable and easy to put on and take off.
Choice C reason: Outdoor grounds are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they are not part of the indoor setting where most falls occur. However, outdoor grounds may pose a fall hazard for patients who go outside for recreation or therapy, and should be checked for uneven surfaces, obstacles, or slippery conditions.
Choice D reason: All four bed rails raised are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they may actually increase the risk of falls and injuries. Bed rails may create a false sense of security, encourage the patient to climb over them, or entrap the patient between the rails and the mattress. Bed rails should be used only when indicated and with the patient's consent.
Choice E reason: None of the above is not the correct answer, as there are two factors in the patient care environment that should be routinely assessed to decrease the risk of falls.
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