An LPN is reviewing the laboratory tests results for a client who has an elevated temperature.
The nurse should identify which of the following findings is a manifestation of dehydration.
Select all that apply.
Increased glucose
Blood creatinine 0.6 mg/dL
Blood osmolarity 260 mOsm/kg
Urine Specific gravity 1.035 .
Correct Answer : A,C,D
Choice A rationale
Increased glucose levels can be a sign of dehydration. When the body is dehydrated, it can cause blood sugar levels to rise.
Choice B rationale
A blood creatinine level of 0.6 mg/dL is within the normal range and does not typically indicate dehydration.
Choice C rationale
An increased blood osmolarity, such as 260 mOsm/kg, can be a sign of dehydration. When the body is dehydrated, the concentration of solutes in the blood can increase, leading to higher osmolarity.
Choice D rationale
A high urine specific gravity, such as 1.035, can indicate dehydration. This measurement reflects the concentration of solutes in the urine, and a high value can mean that the body is conserving water due to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.
Choice B rationale
Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.
Choice C rationale
Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.
Choice D rationale
Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
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