Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation?

Assessing for furrows on the tongue to determine dryness of oral mucous membranes.

Comparing blood pressure measurements in the lying, sitting, and standing positions.

Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L).

Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically.

Answer and Explanation

The Correct Answer is B

Choice A reason: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.

Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.

Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.

Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.

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Correct Answer is ["C","D","F","G","H"]

Explanation

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

A. Fever. B. Positive Cullen’s sign. C. Complaints of indigestion. D. Palpable mass in the left upper quadrant. E. Pain in the upper right quadrant after a fatty meal. F. Vague lower right quadrant abdominal discomfort. G. Pain in left upper abdominal quadrant.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Fever is common in acute cholecystitis due to gallbladder inflammation or infection. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing an acute episode of cholecystitis during evaluation.

Choice B reason: Positive Cullen’s sign indicates intra-abdominal bleeding, not cholecystitis, which causes right quadrant pain. Indigestion is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with acute gallbladder inflammation.

Choice C reason: Indigestion, often with bloating or nausea, supports cholecystitis, as gallstones impair bile flow. This aligns with gastrointestinal assessment, making it a correct manifestation the nurse would identify in a client with an acute cholecystitis episode.

Choice D reason: A palpable mass in the left upper quadrant suggests spleen or gastric issues, not cholecystitis, which affects the right side. Right quadrant pain is correct, making this incorrect, as it doesn’t support the nurse’s diagnosis of acute cholecystitis.

Choice E reason: Pain in the upper right quadrant, especially after fatty meals, is classic in cholecystitis due to gallbladder contraction against obstruction. This aligns with clinical findings, making it a correct manifestation the nurse would expect in acute cholecystitis assessment.

Choice F reason: Vague lower right quadrant discomfort is more typical of appendicitis, not cholecystitis, which causes upper right pain. Fatty meal-related pain is correct, making this incorrect, as it doesn’t align with the nurse’s expected findings in cholecystitis.

Choice G reason: Left upper quadrant pain suggests pancreatic or gastric issues, not cholecystitis, which is right-sided. Right quadrant pain is typical, making this incorrect, as it doesn’t support the nurse’s assessment of acute cholecystitis in the client’s presentation.

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Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

Correct Answer is ["C","D","F","G","H"]

Explanation

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

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The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

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