Prior to conducting a partial assessment with a 72-year-old client the nurse notes that the client intake and output are balanced even though a previous note indicates that the client is dehydrated based upon dry skin
What should the nurse conclude about this information?
1. The client is dehydrated.
2. The accuracy of the earlier assessment is in question.
3. The client's condition has deteriorated.
4. The client has increased fluid intake.
Answer: 2
1. If the client's intake and output are appropriate, it is not likely that the client is dehydrated.
2. The accuracy should be questioned because the elderly experience dry skin with poor turgor as a normal part of aging.
3. The client's output is appropriate so it is not likely that the client has deteriorated.
4. The evidence shows that the client is drinking the appropriate amount of fluid.
You might also like to view...
A woman is having an infertility workup and has been told she has scarring of her fallopian tubes. What action by the nurse is best?
A. Ask the woman how many sexually transmitted infections she has had. B. Assess the woman for previous vaginal infections and their treatment. C. Gently tell the woman that nothing can be done about scarring of the tubes. D. Question the woman about genetic defects or family history of infertility.
What is the rationale for administering a narcotic analgesic and a nonsteroidal anti-inflammatory drug together?
A) To prevent respiratory depression from the narcotic B) To eliminate the need for additional medication during the night C) To combine the medications more effectively and relieve the patient's pain with fewer narcotics D) To eliminate toxic effects of the narcotic
What is the usual treatment for polycythemia?
a. administration of oral or parenteral iron b. low-calorie, low-protein diet c. phlebotomy d. transfusion of RBCs
What must occur before physician-initiated interventions can be carried out?
A) They must be written on the nursing plan of care. B) The nurse relinquishes all responsibility for them. C) Any healthcare provider may order them. D) The physician gives a verbal or written order.