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Question 1 of 5

The nurse is assessing a client with suspected dehydration. Which finding is most indicative?

Correct Answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.

Question 2 of 5

The client tells the nurse, 'I have pain in my left shoulder.' This is considered:

Correct Answer: C

Rationale: Subjective information is provided by a person.

Question 3 of 5

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

Question 4 of 5

A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.

Question 5 of 5

Chorioamnionitis is a maternal infection that is usually associated with:

Correct Answer: A

Rationale: Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes.

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A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

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