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 B
Explanation
A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.
Correct Answer is A
Explanation
A) This response offers a solution by involving a social worker who can assist the client in exploring financial assistance programs or alternative medication options.
B) While contacting the pharmacy may be helpful, it does not guarantee a solution to the client's financial constraints.
C) Involving the occupational therapist for a home visit is not directly related to addressing the client's inability to afford medication.
D) Instructing the client to ask their provider to prescribe a cheaper medication puts the responsibility solely on the client and may not address the underlying issue effectively.
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