A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Distended neck veins

Bounding pulse

BP 146/94 mm Hg

Urine specific gravity 1.034 .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.

In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.

It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.

Choice B rationale:

A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.

A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.

Choice C rationale:

A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:

Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.

A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.

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Correct Answer is C

Explanation

Choice A rationale:

A colostomy is a surgical opening in the abdomen that allows stool to pass through the colon and out of the body. While a colostomy may increase the risk of certain complications, such as dehydration and skin irritation, it does not directly increase the risk of aspiration. This is because the colostomy bypasses the upper digestive tract, where aspiration typically occurs.

Choice B rationale:

An ileostomy is a similar surgical opening in the abdomen, but it diverts the small intestine rather than the colon. Like a colostomy, an ileostomy does not directly increase the risk of aspiration. However, it may lead to dehydration and electrolyte imbalances, which could indirectly contribute to aspiration risk.

Choice C rationale:

Enteral feedings through an NG tube are a common way to provide nutrition to patients who cannot eat by mouth. However, these feedings can also increase the risk of aspiration. This is because the NG tube bypasses the normal swallowing mechanisms, which help to protect the airway. If the feeding tube is not properly positioned or if the patient has impaired gastric motility, formula could enter the lungs and cause aspiration pneumonia.

Choice D rationale:

A chest tube is a drainage tube that is inserted into the chest cavity to remove air or fluid. While a chest tube may cause some discomfort and respiratory issues, it does not directly increase the risk of aspiration.

A. Crackles B. Stridor C. Strong cough D. Deep breathing

Correct Answer is B

Explanation

Choice B rationale:

Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:

Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.

Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.

Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.

Blood or secretions in the airway: These can obstruct the airway and cause stridor.

It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:

Oxygen therapy: This can help to improve the patient's breathing.

Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.

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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?