A hydration assessment consists of checking a variety of parameters, including
a. skin turgor.
b. serum potassium level.
c. capillary refill.
d. serum protein level.
A
A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.
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The nurse plans to teach a patient and the caregiver how to manage high blood pressure (BP). Which action should the nurse take first?
a. Give written information about hypertension to the patient and caregiver. b. Have the dietitian meet with the patient and caregiver to discuss a low sodium diet. c. Teach the caregiver how to take the patient's BP using a manual blood pressure cuff. d. Ask the patient and caregiver to select information from a list of high BP teaching topics.
Nurses use levels of prevention to provide a framework or guide for nursing interventions. Focus is based on the client's needs and the care or service provided. Which of the following is an example of a true health promotion service?
a. An immunization clinic b. A diabetic support group c. A prenatal nutrition class d. A smoking cessation clinic
Which technique of opening the airway in the newly admitted patient with spinal cord injury is the most appropriate?
1. Chin lift 2. Head tilt 3. Jaw thrust 4. Neck flexion
The nurse should provide self-care instructions for the client discharged on terbutaline via pump, including:
a. the pump is programmed only to provide a basal rate of the medication. b. uterine contractions not controlled by two bolus doses within a four-hour period should be reported. c. bolus doses may be used as long as the pulse rate is more than 110 beats per minute. d. the medication is delivered into an intravenous access site.