Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?

Correct Answer: A

Rationale: Monitoring intake and output is essential in assessing for electrolyte imbalances and dehydration in a client with a neurologic deficit. Unlike options B, C, and D, measuring intake and output provides direct information on the client's fluid balance and kidney function. Electrolyte imbalances can lead to neurological complications and alterations in mental status, making it crucial to keep track of the amounts of fluids ingested and excreted by the client. Additionally, dehydration can exacerbate neurological deficits, so monitoring intake and output can help prevent this complication.

Correct Answer: A

Rationale: An oxygen saturation (SaO2) level of 86% is significantly below the normal range of 95-100%. This indicates hypoxemia, which means the body is not getting enough oxygen. In a patient with pneumonia, low oxygen saturation can lead to further respiratory compromise and potential organ damage. Therefore, it is essential for the nurse to notify the physician promptly to obtain an order for supplemental oxygen to correct the hypoxemia and improve the patient's oxygen saturation levels. Delay in addressing low oxygen levels can have serious consequences for the patient's health and recovery.

Correct Answer: B

Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children. Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.

Correct Answer: C

Rationale: The correct size of a suction catheter is usually determined by the patient's weight, rather than height. For James, who weighs approximately 145 lbs, a Fr. 10 suction catheter would be suitable. Suction catheter sizes typically range from Fr. 5 (smaller) to Fr. 18 (larger), with Fr. 10 being a common size for an adult patient of James' weight. Using a catheter that is too small may not effectively clear secretions, while one that is too big may cause discomfort or damage to the airways.

Correct Answer: B

Rationale: Offering softer diet may not address refusal due to developmental factors.