A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)
Hypotension
Bradycardia
Pale yellow urine
Poor skin turgor
Flat neck veins
Correct Answer : A,D,E
A. Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B. Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C. Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D. Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E. Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Ground beef is not the best choice for a client learning about dietary choices. While it is a source of protein, it is also high in saturated fats, which can contribute to heart disease and other health problems. Choice B rationale
Raw vegetables are a good source of fiber and various vitamins and minerals. However, they should be washed thoroughly before consumption to remove any potential contaminants.
Choice C rationale
Fruit with the skin can be a good source of fiber and vitamins. However, like vegetables, they should be washed thoroughly before consumption.
Choice D rationale
High fiber cereals are a great choice for a healthy diet. They can help to regulate bowel movements, lower cholesterol levels, and control blood sugar levels.
Correct Answer is C
Explanation
Choice A rationale
Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.
Choice B rationale
Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.
Choice C rationale
Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.
Choice D rationale
Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.
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