A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Urine output 20 mL/hr

Bradycardia

Sodium 142 mEq/L

Cool skin

Answer and Explanation

The Correct Answer is A

A. Urine output 20 mL/hr: Oliguria, or low urine output (less than 30 mL/hr), is a common sign of dehydration.
B. Bradycardia: Dehydration typically causes tachycardia (increased heart rate) as the body compensates for decreased blood volume.
C. Sodium 142 mEq/L: A sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) and does not indicate dehydration.
D. Cool skin: Dehydration usually results in warm, dry skin due to decreased perfusion and sweating.

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Correct Answer is A

Explanation

A. Temporary urinary retention: After removal of an indwelling catheter, especially in older adults, temporary urinary retention can occur due to decreased bladder tone or urethral irritation.
B. Blood-tinged urine: This is not an expected outcome; it could indicate trauma or infection and should be evaluated.
C. Urinary frequency for several days: While increased frequency might occur immediately after catheter removal, it is not typically expected to last for several days.
D. Highly concentrated urine: Urine concentration would depend on the client's hydration status rather than the removal of the catheter.

A. Allow the client to expel some fluid before continuing. B. Encourage the client to bear down. C. Stop the enema and document that the client did not tolerate the procedure. D. Lower the height of the solution container.

Correct Answer is D

Explanation

A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.

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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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