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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Dysphagia: While dysphagia (difficulty swallowing) can occur in individuals with long-term alcohol use, especially if there is coexisting neurological damage or esophageal disorders, it is not specifically associated with vomiting and diarrhea in the context of this scenario. The primary concern here involves electrolyte imbalances.

B) Hypoactive deep tendon reflexes (DTR): Hypoactive DTRs are typically associated with hypermagnesemia rather than hypomagnesemia. In this case, the client's condition is more likely to lead to electrolyte deficiencies, including hypomagnesemia, due to vomiting, diarrhea, and poor nutritional intake.

C) Hypomagnesemia: Chronic alcohol use often results in nutritional deficiencies, and vomiting and diarrhea can further exacerbate this by depleting electrolytes. Hypomagnesemia is a common finding in long-term alcoholics due to poor dietary intake, gastrointestinal losses, and renal losses. This can lead to symptoms such as muscle weakness, tremors, and altered mental status. Hypomagnesemia is particularly concerning because it can affect cardiovascular stability and neuromuscular function.

D) Positive Chvostek sign: A positive Chvostek sign is indicative of hypocalcemia, which can occur secondary to hypomagnesemia. However, it is not as directly associated with chronic alcoholism as hypomagnesemia itself. The positive Chvostek sign involves a facial muscle spasm in response to tapping the facial nerve and indicates neuromuscular irritability due to low calcium levels. While related, the primary electrolyte imbalance expected here is hypomagnesemia.

A. DSW B. 0.3% NS C. Lactated Ringers D. 0.9% NS

Correct Answer is D

Explanation

A) D5W: Dextrose 5% in water (D5W) is not used with blood transfusions because it can cause hemolysis of the red blood cells due to its hypotonic nature. It can also potentially cause clumping and clotting.

B) 0.3% NS: This is a hypotonic saline solution, which can lead to hemolysis of red blood cells when used as a diluent for blood products. It is not appropriate for use in blood transfusions.

C) Lactated Ringers: Although lactated Ringer's solution is often used for fluid resuscitation, it contains calcium, which can cause clotting in the blood product. Therefore, it is not suitable for use with blood transfusions.

D) 0.9% NS: Normal saline (0.9% sodium chloride) is isotonic and the only solution recommended for use with blood transfusions. It does not cause hemolysis of red blood cells, does not alter the composition of the blood product, and helps to maintain the patency of the IV line. It is the standard diluent used in blood transfusions to ensure the safe administration of blood products.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

﻿A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?

Correct Answer is C

Explanation

A nurse is preparing to give a client an infusion of packed red blood cells (PRBCS). The nurse is priming her administration IV tubing, the nurse primes one side of the Y tubing with the blood and the other should be which solution?

Correct Answer is D

Explanation

﻿A nurse is teaching a client who needs to be on a soft diet. When teaching the client about what he can eat, the nurse should include what food would be indicated in this type of diet?

A nurse is caring for a client who is suffering from dysphagia after a stroke and is currently NPO. Which member of the inter-professional team would the nurse anticipate will be consulted to determine how this client will be safely fed?

A nurse is caring for a client with rheumatoid arthritis. The client is having difficulty with self-feeding due to the pain and hand deformities. The nurse would anticipate a referral will be made to which member of the interprofessional team?

A nurse is providing nutritional education to a client recently diagnosed with high cholesterol. The nurse should provide the client with which statements regarding their diet restrictions?

A nurse is calculating a client's body mass index (BMI). Which of the following information does the nurse require?

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL (9-10.5 mg/dL). Which finding should the nurse expect during the initial assessment?

A nurse is caring for a client with severe anemia. The provider placed an order for one unit of packed red blood cells (PRBCs) x 1 now. The nurse should anticipate the blood will be completely infused after how much time?

A nurse is caring for a client with an order for one unit of packed red blood cells (PRBCs). The nurse should anticipate to remain ate client's bedside during which time period of the infusion?