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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Clean gloves should be worn when entering the room of a client with MRSA to prevent contact transmission of the bacteria. Gloves should be put on before any contact with the client or potentially contaminated surfaces and should be removed and disposed of properly after leaving the room.
B. A surgical mask is generally not necessary for routine care of a client with MRSA unless there is a risk of splashes or sprays of bodily fluids. The main mode of transmission for MRSA is contact, so gloves are the primary protective measure.
C. Sterile gloves are typically not required unless performing sterile procedures directly involving the wound or handling sterile equipment. For routine assessment of the client's pulse, clean gloves are sufficient.
D. Protective eyewear is not necessary for routine care such as checking a client's pulse. It is primarily used when there is a risk of splashes or sprays that could potentially reach the eyes.

A. Decreased hematocrit B. Increased urine ketones C. Increased urine specific gravity D. Decreased BUN

Correct Answer is C

Explanation

A. Hematocrit measures the percentage of red blood cells in the blood. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, resulting in an increase in hematocrit rather than a decrease. Therefore, a decreased hematocrit would not be an expected finding in fluid volume deficit.
B. Urine ketones are typically elevated in conditions where there is increased fat metabolism, such as in diabetic ketoacidosis or starvation. They are not directly related to fluid volume deficit and would not be an expected finding.
C. Urine specific gravity measures the concentration of solutes in the urine, indicating the kidney's ability to concentrate or dilute urine. In fluid volume deficit, the body conserves water, leading to increased urine concentration and higher urine specific gravity. Therefore, increased urine specific gravity is an expected finding in fluid volume deficit.
D. BUN is a measure of kidney function and protein metabolism. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, which can lead to an increase in BUN rather than a decrease. A decreased BUN would not typically be an expected finding in fluid volume deficit.

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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?

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