A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
Distended jugular veins
Pitting, dependent edema
Decreased blood pressure
Increased blood pressure
The Correct Answer is C
A) Distended jugular veins are associated with fluid overload, not dehydration.
B) Pitting, dependent edema is also associated with fluid overload, not dehydration.
C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Explanation
A) Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B) Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C) Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D) Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E) Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F) Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G) Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.
Correct Answer is D
Explanation
A. While pain assessment is important, ensuring airway patency takes priority over pain assessment in a client who has received sedation.
B. Monitoring temperature is important but is not the priority in this scenario.
C. Warmth of extremities is not as critical as assessing the airway.
D. Gag reflex assessment is essential to evaluate the client's ability to protect their airway and prevent aspiration, especially after receiving sedation.
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