When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?
Check for external rectal hemorrhoids.
Note inflammation in the perineal area.
Observe for signs of fluid volume deficit.
Determine any changes in sleep patterns.
The Correct Answer is C
A. Check for external rectal hemorrhoids: Hemorrhoids may cause discomfort during diarrhea, but they are not the most urgent concern. The primary issue with severe diarrhea is the risk of dehydration and electrolyte imbalance, which can become life-threatening.
B. Note inflammation in the perineal area: While important for skin care and comfort, perineal inflammation does not pose the immediate systemic risk that fluid volume deficit does. Skin assessment can be addressed after ensuring the client's vital signs and hydration status are stable.
C. Observe for signs of fluid volume deficit: Severe diarrhea leads to significant fluid and electrolyte losses. Signs such as hypotension, tachycardia, dry mucous membranes, and decreased urine output indicate fluid volume deficit, which requires urgent intervention to prevent shock and organ dysfunction.
D. Determine any changes in sleep patterns: Sleep disturbances can occur with illness but are not as immediately critical to assess as fluid and electrolyte status. Identifying fluid volume deficit must be prioritized to prevent rapid clinical deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["840"]
Explanation
Convert each fluid intake into mL:
At 0730, the client consumed 120 mL of orange juice.
At 1130, the client consumed 1 cup of broth (1 cup = 240 mL) and 120 mL of apple juice.
At 1400, the client consumed a 12-ounce can of soft drink. Since 1 ounce = 30 mL, 12 ounces equals 360 mL.
Total fluid intake:
120 mL (orange juice)
240 mL (broth)
120 mL (apple juice)
360 mL (soft drink)
Add the total fluid intake:
120 mL + 240 mL + 120 mL + 360 mL = 840 mL
Answer: 840 mL
Correct Answer is B
Explanation
A. Show the UAP how to use a transfer belt to safely move the client: A transfer belt is useful for clients who can bear some weight and follow instructions. Since the client is confused and cannot bear weight, using a transfer belt is unsafe and increases the risk of injury.
B. Work with the UAP to use a mechanical lift and sling for the transfer: A mechanical lift provides the safest method for transferring a confused, non-weight-bearing client. It minimizes the risk of injury to both the client and staff while ensuring the transfer is done safely and correctly.
C. Instruct the UAP to use a pivot technique when moving the client: Pivot techniques require the client to bear weight and follow simple directions, neither of which is appropriate given the client's confusion and inability to bear weight.
D. Notify the charge nurse that the client cannot be transferred: While updating the charge nurse may eventually be needed, the immediate action is to modify the transfer method to ensure the client's needs are safely met using appropriate equipment.
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