A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Correct Answer: B

Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.

Correct Answer: A

Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.

Correct Answer: C

Rationale: The correct way to prepare a suspension before administration is by shaking it so that all the drug particles are dispersed uniformly. Suspending agent particles settle over time, creating a layer of liquid at the top and a layer of solid at the bottom. By shaking the suspension, the nurse ensures that the drug particles are fully mixed and distributed evenly throughout the liquid. This step is crucial to ensure that the patient receives the correct dosage of the medication with each administration. Diluting the suspension with normal saline or dextrose solutions or crushing remaining particles with a mortar and pestle are not recommended methods for preparing a suspension before administration.

Correct Answer: B

Rationale: The presentation of perianal inflammation with satellite lesions that cross the inguinal folds is highly suggestive of a Candida albicans (yeast) diaper rash. Yeast diaper rash is characterized by redness, swollenness, and usually involves the skin folds. The warm, moist environment created by a diaper provides an ideal setting for Candida albicans to grow and cause a rash. The presence of satellite lesions that cross the inguinal folds further supports the diagnosis of a yeast infection rather than other causes like impetigo, irritation from urine and feces, or infrequent diapering. Treatment for yeast diaper rash typically involves antifungal creams or ointments.

Correct Answer: D

Rationale: In stable asthmatic patients, additional interventions like systemic steroids or increased beta-agonist doses are not always necessary unless there are signs of exacerbation.