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 D

Explanation

A. Indwelling urinary catheters are associated with an increased risk of urinary tract infections (UTIs) and other complications, including skin irritation and breakdown around the catheter site. Routine use of indwelling catheters is not recommended for managing routine urinary incontinence due to these risks.

B. Using hot water or harsh cleansers can strip the skin of its natural oils and lead to further irritation and breakdown. Instead, gentle cleansing with mild soap and warm water is recommended after each episode of incontinence to remove urine and prevent skin irritation. Patting the skin dry rather than rubbing can also help prevent damage to the skin barrier.
C. Regular skin assessment is crucial in clients with urinary incontinence to identify early signs of skin breakdown. Checking the skin every 8 hours may not be frequent enough, particularly if the client is incontinent frequently. More frequent assessment, ideally after each episode of incontinence or at least every 2-4 hours, is recommended to promptly identify and address any skin issues.
D. Applying a moisture barrier ointment or cream to the perineal area and any areas prone to moisture can help protect the skin from urine and fecal exposure. These products create a barrier that prevents direct contact of urine with the skin, reducing the risk of irritation and breakdown. Regular application, especially after cleansing and as needed throughout the day, can help maintain skin integrity.

A. The oliguric phase lasts for 2 days. B. The client's urine output is less than 400 mL per 24 hours. C. The oliguric phase begins within 1 month of the injury. D. The client's BUN and creatinine decreases during this phase.

Correct Answer is B

Explanation

A. The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B. During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C. The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D. During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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