KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to find initially before fluid balance reaches homeostasis?
Crackles to Bilateral lobes
Tenting skin and wet mucous membranes
C Tachycardia and hypotension
+4 edema to bilateral lower extremities and confusion
The Correct Answer is C
Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with fluid overload, but not with dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
: A client with renal disease may have impaired kidney function, which can affect fluid balance in the body. Giving fluids too quickly or increasing the infusion rate too quickly can lead to fluid overload,
which can exacerbate the client's condition. It is important for the nurse to monitor the amount of fluid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent fluid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.
Correct Answer is D
Explanation
Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.
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