A middle-aged adult client with nausea and vomiting for three days presents to the emergency room.
Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.
Increased heart rate.
Decreased blood pressure.
Increased temperature.
Hypoactive muscle responses.
Alert and oriented.
Correct Answer : A,B
Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.
Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.
Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.
Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.
Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:
- Heart rate: 60 to 100 beats per minute for adults
- Blood pressure: less than 120/80 mmHg for adults
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.
Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.
Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.
Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.
Correct Answer is D
Explanation
30 mL. This is because one ounce is equal to 29.57353 milliliters, so one ounce of an elixir medication is approximately 30 milliliters.
The nurse should instruct the client to take 30 milliliters of the medication during discharge teaching.
Choice A is wrong because 5 milliliters is much less than one ounce. Choice B is wrong because 15 milliliters is half of one ounce.
Choice C is wrong because 25 milliliters is slightly less than one ounce.
The nurse should use a conversion factor or a calculator to convert ounces to milliliters accurately.
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