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. This position, where the client is seated in a semi-upright sitting position, helps to reduce the risk of aspiration and facilitates breathing. It is also conducive to the proper functioning of the nasogastric tube for decompression.
B. Moistening the client's lips is also important for comfort, but it does not directly relate to the management of the nasogastric tube.
C. Sterile water should be used for irrigation only if the tube becomes clogged.
D. Measuring abdominal girth is important but not specific to nasogastric tube care.

A. Celery B. Pears with skin C. Canned pineapple D. Mashed potatoes

Correct Answer is B

Explanation

A. Celery is a low-calorie vegetable that contains some fiber (about 1.6 grams per 100 grams). While it provides some fiber, there are other options with higher fiber content.

B. Pears with their skin are an excellent source of dietary fiber. A medium-sized pear with skin provides about 5.5 grams of fiber. The skin of the pear is particularly rich in insoluble fiber, which aids in digestion and helps prevent constipation.
C. Canned pineapple generally has lower fiber content compared to fresh fruits. Most of the fiber in pineapple comes from the fruit itself, and processing can reduce the fiber content. Therefore, canned pineapple is not as high in fiber compared to other options.
D. Mashed potatoes, especially if they are peeled, are relatively low in fiber. They are primarily a starchy vegetable and do not provide significant amounts of dietary fiber unless consumed with the skin.

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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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