A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?
Bradycardia
Edema
Hypotension
Crackles
The Correct Answer is C
A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
Correct Answer is D
Explanation
A. I will turn the car seat forward facing when my baby is 1 year old. This is incorrect because the American Academy of Pediatrics recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight limit specified by the car seat manufacturer.
B. I will place the retainer clip on my baby's upper abdomen. This is incorrect because the retainer clip should be positioned at armpit level to properly secure the straps and protect the baby in case of a collision.
C. I will position the shoulder harness straps 3 inches above my baby's shoulders. This is incorrect because for a rear-facing car seat, the shoulder harness straps should be positioned at or just below the infant’s shoulders, not above.
D. I will position my baby at a 45-degree angle in the car seat. This is correct because positioning the baby at a 45-degree angle helps maintain an open airway and prevents airway obstruction due to the head falling forward.
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