Nurse Assessing Client Question & Answer Guide (With Explanation)

This question tests key academic concepts commonly covered in coursework.

What This Question Is About

This question relates to nurse assessing client and requires a structured academic response.

How to Approach This Question

Start by identifying the main issue, then apply relevant academic frameworks.

Key Explanation

This topic involves nurse assessing client. A strong answer should include explanation, application, and examples.

Original Question

The nurse is assessing a client who had a total hip replacement 2 days ago. The client has profuse diaphoresis. Vital signs are temperature 101°F (38.3°C); pulse 90 bpm; and respiration rate 20 breaths/min. The intravenous (IV) line is infusing at 31 drops per minute. The client received morphine 1 hour ago and reports a pain level of 2 on a 0-to-10 scale. The client had eggs, toast, and orange juice for breakfast. The dressing is dry. The nurse reviews the client’s prescriptions. Which action(s) should the nurse take to prevent the client from becoming dehydrated? Select all that apply. Prescriptions 1. Diet as tolerated 2. Physical therapy to ambulate the client two times a day 3. Acetaminophen 325 mg, 2 tablets every 4 hours for a temperature over 100°F (37.7°C) 4. Morphine 10 mg, IV push every 4 hours 5. 10,000 mL dextrose 5% in water (D5W) every 8 hours Ask the health care provider to increase the amount of IV fluids. Administer acetaminophen. Have the client maintain bed rest. Teach the client how to inspect the incision site for bleeding. Administer morphine. Encourage the client to drink 500 mL of fluids each shift.

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