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

ATI LPN

PN ATI Comprehensive Predictor

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

A. Administer antiemetics to prevent nausea
B. Monitor electrolyte levels to prevent imbalances
C. Administer oral rehydration solutions
D. Administer intravenous fluids

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 are the key differences between systolic and diastolic heart failure?

A. Systolic: Reduced ejection fraction; Diastolic: Preserved ejection fraction
B. Systolic: Preserved ejection fraction; Diastolic: Reduced ejection fraction
C. Systolic: Right-sided heart failure; Diastolic: Left-sided heart failure
D. Systolic: Pulmonary congestion; Diastolic: Systemic congestion

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.

3. What is the most important action when providing wound care to a client with a pressure ulcer?

A. Apply a dry, sterile dressing to the wound
B. Cleanse the wound with normal saline
C. Perform a wound culture before applying ointment
D. Cover the wound with a wet-to-dry dressing

Correct answer: C

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care to a client with a pressure ulcer. This action helps identify any underlying infections, allowing healthcare providers to select the most appropriate treatment. Options A, B, and D are not as critical as performing a wound culture, as they focus on wound dressing and cleansing rather than identifying potential infections.

4. A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?

A. Administer an antiemetic
B. Irrigate the NG tube with sterile water
C. Increase the suction setting
D. Replace the NG tube

Correct answer: B

Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.

5. A client receiving chemotherapy has developed stomatitis. Which of the following interventions should the nurse implement?

A. Provide lemon-glycerin swabs
B. Encourage the client to eat soft foods
C. Avoid using toothpaste
D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis is to encourage them to eat soft foods. Soft foods help prevent further irritation of the mouth, making it easier for the client to eat and reducing discomfort. Providing lemon-glycerin swabs could be too harsh on the already irritated mucosa. Avoiding toothpaste is relevant for clients with stomatitis to prevent further irritation. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol can further irritate the mucosa.