A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
Skin tenting
BP 178/90 mm Hg
Red mucous membranes
Jugular vein distention
The Correct Answer is A
A. Skin tenting occurs when the skin loses its elasticity due to dehydration. When gently pinched, the skin may remain elevated and return to its normal position slowly. This finding is a classic sign of dehydration and indicates that the client has lost significant fluid volume.
B. Elevated blood pressure (BP) can sometimes be associated with dehydration, especially in acute cases or when there are underlying conditions like hypovolemia. However, it is not typically a primary indicator of dehydration. Hypotension (low blood pressure) is more commonly associated with severe dehydration.
C. Red mucous membranes may indicate various conditions, including dehydration. Dehydration can lead to dryness and mucosal irritation, resulting in redness. However, red mucous membranes alone are not specific enough to reliably indicate dehydration without considering other signs and symptoms.
D. Jugular vein distention (JVD) is associated with fluid overload rather than dehydration. It occurs when there is increased pressure in the venous system, often due to heart failure or fluid retention. JVD is not typically seen in dehydrated individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B. This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C. Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D. Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.
Correct Answer is A
Explanation
A. Atrial fibrillation is characterized by an irregularly irregular pulse. This means that the rhythm of the pulse lacks a discernible pattern; it may be irregularly fast or slow, with varying intervals between beats. Therefore, "irregular" is an appropriate term to describe the quality of the pulse in a client with atrial fibrillation.
B. While some clients with atrial fibrillation may have a slow heart rate (bradycardia), not all do. Atrial fibrillation itself typically presents with an irregular rhythm rather than a consistently slow pulse rate. Thus, "slow" may not accurately describe the quality of the pulse in atrial fibrillation.
C. "Not palpable" refers to the inability to feel or detect a pulse. In atrial fibrillation, the pulse is usually palpable but irregular. Therefore, "not palpable" would not be an accurate term to describe the pulse quality in this condition.
D. "Bounding" describes a pulse that is strong and forceful. In atrial fibrillation, the pulse may vary in strength and typically does not have a bounding quality. This term would not accurately describe the pulse quality in a client with atrial fibrillation.
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