A nurse is collecting data from a patient who has dehydration. Which of the following findings should the nurse expect?
Moist skin
Dark-colored urine
High blood pressure
Distended neck veins
The Correct Answer is B
Choice A reason: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice B reason: Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice C reason: Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice D reason: Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.
Correct Answer is D
Explanation
Choice A reason: Producing phosphate buffers is not the main function of the kidneys in response to acid-base disturbances. Phosphate buffers are mainly found in the intracellular fluid and the urine, where they help to maintain the pH by binding or releasing hydrogen ions.
Choice B reason: Adjusting PaCO2 levels is not the function of the kidneys, but rather the function of the lungs in response to acid-base disturbances. The lungs regulate the PaCO2 levels by increasing or decreasing the rate and depth of respiration, which affects the amount of carbon dioxide exhaled.
Choice C reason: Producing protein buffers is not the function of the kidneys, but rather the function of the cells and the plasma in response to acid-base disturbances. Protein buffers are the most abundant and versatile buffers in the body, as they can act as acids or bases by donating or accepting hydrogen ions.
Choice D reason: Excreting or reabsorbing hydrogen or bicarbonate is the main function of the kidneys in response to acid-base disturbances. The kidneys regulate the HCO3- levels by either reabsorbing it from the filtrate or generating it from carbon dioxide and water. The kidneys also regulate the hydrogen ion levels by either excreting it into the urine or exchanging it for sodium ions.
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