Among the following, which is not a clinical finding of a severely dehydrated patient?

Skin pallor and cool-to-touch skin

Pitting edema

Tachycardia with thready pulse

Lung sounds diminished with crackles upon auscultation

Urine Specific gravity of 1.035 D. Blood sodium 150 mEq/L

Answer and Explanation

The Correct Answer is B

Choice A rationale

Skin pallor and cool-to-touch skin are common signs of severe dehydration. When the body is severely dehydrated, blood flow to the skin decreases, causing the skin to feel cool and look pale.

Choice B rationale

Pitting edema is not a clinical finding of severe dehydration. In fact, it’s quite the opposite. Pitting edema is a condition that causes swelling due to fluid accumulation, often due to conditions like heart failure, liver disease, or kidney disease.

Choice C rationale

Tachycardia with a thready pulse is a common sign of severe dehydration. The heart rate increases in an attempt to maintain blood flow to the organs, and the pulse may feel weak or thready due to low blood volume.

Choice D rationale

Lung sounds diminished with crackles upon auscultation is not typically associated with dehydration. This is more commonly seen in conditions affecting the lungs such as pneumonia or heart failure.

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Correct Answer is D

Explanation

Choice A rationale

While electrolyte balance is important in patient care, it is not the primary reason for measuring gastric residual before administering a feeding through an NG tube.

Choice B rationale

Confirming the placement of the NG tube is crucial before administering a feeding. However, measuring the gastric residual is not the primary method used to confirm tube placement.

Choice C rationale

Removing gastric acid that might cause dyspepsia is not the main purpose of measuring gastric residual. Dyspepsia, or indigestion, is typically managed with medications and dietary modifications.

Choice D rationale

The primary purpose of measuring gastric residual is to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. If gastric emptying is delayed, the nurse should avoid overfeeding the patient and causing gastric distention.

A. Administer glucagon IM. B. Discontinue the TPN infusion. C. Request a potassium replacement. D. Check the patient for a positive Chvostek’s sign.

Correct Answer is C

Explanation

The correct answer is Choice C.

Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.

Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement

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Among the following, which is not a clinical finding of a severely dehydrated patient?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is reviewing the laboratory values of a patient receiving total parenteral nutrition (TPN). The glucose is 72 mg/dL, chloride is 100 mEq/L, sodium is 138 mEq/L, and potassium is 3.0 mEq/L. What action should the nurse plan to take?

Correct Answer is C

Explanation

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