A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?
Dark-colored urine
High blood pressure
Distended neck veins
Moist skin
The Correct Answer is A
A. Dark-colored urine is a common finding in dehydration, indicating concentrated urine.
B. Dehydration is more likely to be associated with hypotension rather than high blood pressure.
C. Distended neck veins are more associated with fluid overload, not dehydration.
D. Moist skin is not a typical finding in dehydration; dry skin is more common.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The drip chamber should not be filled completely with blood, as this can cause clotting and occlusion.
B. The blood should not be infused for more than 4 hr, as this increases the risk of bacterial contamination and transfusion reactions.
C. Medications are usually administered separately from blood products to avoid incompatibility.
D. The packed RBCs should be connected by Y tubing to normal saline to prevent hemolysis and maintain fluid balance. This is an expected finding because it allows the nurse to flush the line with normal saline before and after the blood transfusion, and to switch to normal saline in case of a transfusion reaction.
Correct Answer is B
Explanation
A: Hypervolemia is often associated with increased fluid volume, which typically results in an increased heart rate (tachycardia), not bradycardia.
B: Peripheral edema is a common manifestation of hypervolemia due to the excess fluid in the extracellular space.
C: Hypervolemia is more likely to cause increased blood pressure (hypertension), not hypotension.
D: Oliguria (decreased urine output) is associated with hypovolemia, not hypervolemia.
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