A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Blood pressure 178/90 mm Hg

Edema

Bounding bilateral pulses

Increased urine specific gravity

Answer and Explanation

The Correct Answer is D

A) Blood pressure 178/90 mm Hg: Elevated blood pressure is more commonly associated with fluid overload or hypertension rather than dehydration. In dehydration, one would expect to see a decrease in blood pressure, particularly orthostatic hypotension, due to a reduction in blood volume.

B) Edema: Edema indicates fluid retention in the tissues, which is a sign of fluid overload rather than dehydration. Dehydration typically results in reduced extracellular fluid volume, leading to symptoms like dry mucous membranes and poor skin turgor, rather than swelling.

C) Bounding bilateral pulses: Bounding pulses are usually seen in conditions of increased cardiac output or fluid overload, where there is an excess of fluid volume. In contrast, dehydration often leads to weak and thready pulses due to decreased circulatory volume.

D) Increased urine specific gravity: Increased urine specific gravity is a direct indicator of dehydration. It occurs because the kidneys concentrate urine to conserve water, leading to a higher concentration of solutes in the urine. This is a reliable clinical marker of reduced hydration status, reflecting the body's attempt to maintain fluid balance by conserving water.

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Correct Answer is C

Explanation

A) Discontinue cardiac monitoring during the infusion:

Discontinuing cardiac monitoring during the infusion of potassium chloride is unsafe. Potassium infusions can significantly impact cardiac function, so continuous cardiac monitoring is necessary to detect any arrhythmias or other complications.

B) Administer KCI as a rapid IV bolus:

Administering potassium chloride as a rapid IV bolus is contraindicated due to the risk of severe adverse effects, including cardiac arrest. Potassium should be infused slowly to avoid complications.

C) Only give the KCI via a central venous line:

Potassium chloride is ideally administered through a central venous line because it is irritating to veins and can cause damage if given through a peripheral line. A central line reduces the risk of irritation and allows for safer infusion of potassium.

D) Infuse the KCI at a rate of 10 mEq/hour:

Infusing potassium chloride at a rate of 10 mEq/hour is generally too slow for an emergency situation requiring immediate correction of severe hypokalemia. For more urgent cases, higher rates may be required, but only under strict medical supervision to avoid complications.

A. 8 hr B. 4 hr C. 6 hr D. 2 hr

Correct Answer is D

Explanation

A. 8 hr - Infusing one unit of packed red blood cells (PRBCs) over 8 hours is too long. Typically, PRBCs are infused over a shorter period to avoid complications.

B. 4 hr - Infusing PRBCs over 4 hours is still within acceptable limits, but the standard time for PRBC transfusion is usually shorter.

C. 6 hr - Infusing PRBCs over 6 hours is longer than usual. The recommended duration for infusing one unit of PRBCs is generally shorter.

D. 2 hr - The standard time to infuse one unit of PRBCs is typically between 1.5 to 2 hours. This duration helps ensure the effective delivery of red blood cells while minimizing the risk of transfusion reactions.

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A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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