which of the following is the priority for a client with dehydration
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Nursing Elites

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1. What is the priority for a client with dehydration?

Correct answer: B

Rationale: The priority for a client with dehydration is to monitor electrolyte levels to prevent imbalances. Dehydration can lead to electrolyte disturbances, which can have serious consequences. Administering antiemetics (Choice A) may help with nausea but does not address the root cause of dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels is crucial in managing dehydration. Administering intravenous fluids (Choice D) is important in severe cases of dehydration, but monitoring electrolytes should come first to assess the extent of the imbalance and guide fluid replacement therapy effectively.

2. What is the priority in managing a client diagnosed with delirium?

Correct answer: B

Rationale: The priority in managing a client diagnosed with delirium is to identify any underlying causes. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. By determining the root cause, healthcare providers can address the issue effectively and tailor the treatment plan accordingly. Administering anti-anxiety medication (Choice A) may help manage symptoms but does not address the underlying cause of delirium. Similarly, reducing environmental stimulation (Choice C) and encouraging deep breathing exercises (Choice D) may provide some relief, but they do not target the primary concern of identifying and addressing the underlying causes of delirium.

3. A nurse is caring for a client who has a serum sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: Abdominal cramping is a common manifestation of hyponatremia, as the sodium imbalance affects muscle function. Numbness of the extremities (Choice A) is more commonly associated with electrolyte imbalances such as hypocalcemia. Bradycardia (Choice C) is not typically a direct manifestation of hyponatremia. Positive Chvostek's sign (Choice D) is related to hypocalcemia, not hyponatremia.

4. What are the risk factors for deep vein thrombosis (DVT) and how can it be prevented?

Correct answer: A

Rationale: The correct answer is A: Immobility and oral contraceptive use. Immobility and oral contraceptive use are significant risk factors for deep vein thrombosis (DVT). Immobility leads to blood stasis, increasing the risk of clot formation, while oral contraceptive use can promote hypercoagulability. Prevention strategies for DVT include promoting mobility to enhance blood circulation and using anticoagulants to prevent clot formation. Choices B, C, and D are incorrect. While pregnancy and smoking can increase the risk of DVT, they are not the specific factors mentioned in the question. Similarly, obesity and varicose veins, as well as hypertension and high cholesterol, are not the primary risk factors associated with DVT.

5. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?

Correct answer: C

Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

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