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 A

Explanation

Choice A reason: Octreotide reduces portal hypertension and bleeding in esophageal varices by constricting splanchnic blood flow. This aligns with acute variceal bleed management, making it the correct medication the nurse would expect to be administered to the actively bleeding client.

Choice B reason: Propranolol prevents variceal bleeding long-term but is not used for active bleeding. Octreotide is acute treatment, making this incorrect, as it’s inappropriate for the nurse’s expectation in managing the client’s immediate esophageal variceal hemorrhage.

Choice C reason: Lactulose treats hepatic encephalopathy, not active variceal bleeding. Octreotide controls acute hemorrhage, making this incorrect, as it’s unrelated to the nurse’s priority of administering a medication to stop the client’s esophageal variceal bleeding in the emergency.

Choice D reason: Spironolactone manages ascites in liver disease, not acute variceal bleeding. Octreotide is the treatment for active bleeding, making this incorrect, as it’s irrelevant to the nurse’s expectation for a medication to control the client’s esophageal variceal hemorrhage.

A. Shortness of breath. B. Lightheadedness. C. Dry cough. D. Bitter taste in the mouth.

Correct Answer is B

Explanation

Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.

Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.

Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.

Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.

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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

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Correct Answer is A

Explanation

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

Correct Answer is B

Explanation

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

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