When examining the skin during a physical examination, what is the most important factor a nurse needs to assess in a client who is dehydrated due to fluid losses from the gastrointestinal (GI) tract?
A) Check if the skin is discolored.
B) Check if the mucous membranes are dry.
C) Examine the sclera if it is yellow.
D) Examine for distended abdominal veins.
B
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A nurse plans care for a client with a growth hormone deficiency. Which action should the nurse include in this client's plan of care?
a. Avoid intramuscular medications. b. Place the client in protective isolation. c. Use a lift sheet to re-position the client. d. Assist the client to dangle before rising.
The nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates the resolution of the infection? Select all that apply
A) Lung fields documented as clear in the bases. B) Palpable vibrations over the chest wall when the client speaks. C) Decreased fremitus when the client speaks "99." D) Dull sounds percussed over the lung tissue. E) Bronchovesicular sounds heard over the upper lung fields.
When collecting a sputum specimen, the person coughs up sputum from the:
a. Mouth b. Throat c. Upper airway d. Bronchi and trachea
A nurse can expect that which of the following patients are likely to suffer from fecal incontinence? Select all that apply
1. An 84-year-old with dementia 2. A 39-year-old paraplegic 3. A 26-year-old with mental challenges 4. A 54-year-old with diverticulosis 5. A 75-year-old with voluntary control