A nurse is caring for a patient who has been admitted for dehydration. What assessment data will show to nurse the patient's fluid status?
Pedal Pulses
Skin Integrity
Intake and Output
Temperature
The Correct Answer is C
A. Pedal Pulses: While assessing pedal pulses can provide information about circulation, they are not a direct indicator of hydration status. Pulse quality may be affected by other factors such as vascular disease or cardiac output, making this a less reliable measure.
B. Skin Integrity: Skin integrity assesses for potential breakdown or wounds. Although dehydration can affect skin turgor, this alone is insufficient to evaluate fluid balance comprehensively, especially in older adults where elasticity changes naturally with age.
C. Intake and Output: Monitoring fluid intake and urine output provides the most accurate and immediate data on fluid balance. It helps determine if the patient is retaining, losing, or maintaining fluids, making it a primary tool for assessing hydration.
D. Temperature: Elevated temperature may indicate infection or inflammation, which can contribute to fluid loss, but temperature changes alone are not a reliable measure of overall fluid status. It is an indirect and nonspecific indicator.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Drinking sixteen to twenty 12-oz glasses (5,760 to 7,200 mL) is excessive and could lead to fluid overload, especially in older adults who may have compromised cardiac or renal function.
B. Drinking six to eight 8-oz glasses (1,500 to 2,000 mL) per day aligns with general hydration recommendations for older adults. This volume supports adequate hydration without risking overload and helps maintain normal physiological functions.
C. One to two 4-oz glasses (120 to 240 mL) per day is insufficient for maintaining proper hydration and could lead to recurrent dehydration.
D. Five to six 6-oz glasses (900 to 1,080 mL) per day is slightly below the recommended intake and may not meet the hydration needs of most older adults, especially after dehydration.
Correct Answer is D
Explanation
A. based on the conversation with the patient, the patient is unhappy with care: This statement includes the nurse’s interpretation rather than the patient’s exact words and feelings, which is less objective for documentation.
B. upon interaction with the patient, the patient seems angry today: This phrase is subjective and vague, lacking specific patient statements or observable behaviors, making it less precise for clinical records.
C. the patient is angry, unsatisfied with care, and wants to go home: This summarizes the nurse’s opinion rather than providing direct quotes or factual observations, which is not ideal for accurate documentation.
D. patient states, “I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today.”: This is a direct quote from the patient, providing clear, objective documentation of the patient’s feelings and statements.
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