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 D

Explanation

Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.

Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.

Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.

Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.

A. Eating leafy green vegetables with a glass of water. B. Eating apple slices with carrots. C. Eating a steak with mushrooms. D. Eating calf’s liver with a glass of orange juice.

Correct Answer is D

Explanation

Choice A reason: Leafy greens contain iron, but water doesn’t enhance absorption; vitamin C does. Calf’s liver with orange juice maximizes absorption, making this incorrect, as it lacks the vitamin C component the nurse should teach to improve iron uptake in anemia.

Choice B reason: Apples and carrots have minimal iron and no vitamin C to enhance absorption. Calf’s liver with orange juice is optimal, making this incorrect, as it doesn’t provide iron or absorption enhancers compared to the nurse’s teaching for iron deficiency anemia.

Choice C reason: Steak is iron-rich, but mushrooms don’t significantly enhance absorption like vitamin C. Orange juice with liver is better, making this incorrect, as it’s less effective than the nurse’s recommendation to pair iron with a vitamin C source for anemia.

Choice D reason: Calf’s liver is high in iron, and orange juice’s vitamin C enhances non-heme iron absorption. This aligns with nutritional education for iron deficiency anemia, making it the correct choice for the nurse to teach the client to improve iron absorption effectively.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

Correct Answer is D

Explanation

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

Correct Answer is D

Explanation

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