A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

(Select All that Apply.)

Bradycardia

Pale Yellow Urine

Poor Skin Turgor

Hypotension

Flat Neck Veins

Answer and Explanation

Correct Answer : C,D,E

A. Bradycardia: Vomiting and diarrhea usually lead to tachycardia (increased heart rate) as the body compensates for hypovolemia, not bradycardia (slow heart rate).

B. Pale Yellow Urine: Dehydration often causes the urine to become concentrated and dark yellow, not pale yellow.

C. Poor Skin Turgor: Poor skin turgor is a classic sign of dehydration caused by fluid loss.

D. Hypotension: Loss of fluid volume can result in hypotension due to reduced blood circulation.

E. Flat Neck Veins: Dehydration causes reduced venous return, leading to flat neck veins, particularly when lying down.

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Correct Answer is C

Explanation

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

A. Vital signs B. skin turgor C. Daily input and output D. Daily weights

Correct Answer is D

Explanation

A. Vital signs: Vital signs can reflect changes in fluid status, but they are not always sensitive to small shifts in fluid balance and can be affected by many other factors like medications.

B. Skin turgor: Skin turgor can be useful for assessing dehydration but is not a reliable indicator for tracking fluid balance over time, especially in older adults where skin elasticity naturally declines.

C. Daily input and output: Monitoring intake and output is useful, but it is not the most reliable for evaluating overall fluid balance, especially in cases of insensible loss or shifts in third spaces.

D. Daily weights: Weighing the patient daily is the most reliable method for monitoring fluid balance because it directly reflects changes in fluid retention or loss, particularly in acute or chronic conditions like heart failure or dehydration.

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A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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