The nurse is caring for a client admitted with dehydration who has been receiving intravenous (IV) fluid replacement. Which finding indicates effective treatment?
Urine specific gravity 1.038
Urine output 25 mL/hour
Mean arterial pressure 58
Heart rate 88 beats/minute
The Correct Answer is D
A. A urine specific gravity of 1.038 is significantly elevated above the normal physiological range of 1.005 to 1.030. This finding indicates that the urine remains highly concentrated, suggesting that the kidneys are still conserving water due to a continued state of fluid volume deficit. Effective rehydration would result in a lower, more dilute specific gravity as the circulating volume and renal perfusion normalize.
B. A urine output of 25 mL/hour is below the standard clinical threshold of 30 mL/hour, which is the minimum required to ensure adequate organ perfusion and metabolic waste excretion. Persistent oliguria indicates that the compensatory mechanisms for dehydration are still active and that the fluid resuscitation has not yet achieved hemodynamic stability. The nurse should continue to monitor and potentially escalate fluid therapy until output meets or exceeds 30 mL/hour.
C. A mean arterial pressure of 58 mmHg is critically low and insufficient to maintain adequate perfusion to vital organs, particularly the brain and kidneys. Normal mean arterial pressure should be maintained at 65 mmHg or higher to ensure systemic homeostasis. This hypotensive value suggests that the client is still experiencing a significant volume deficit or is potentially progressing toward hypovolemic shock despite the current IV fluid replacement.
D. A heart rate of 88 beats/minute falls within the normal adult reference range of 60 to 100 beats/minute. Dehydration typically causes compensatory tachycardia as the body attempts to maintain cardiac output in the presence of decreased stroke volume. The normalization of the heart rate is a reliable indicator that the intravascular volume has been restored and the sympathetic nervous system's compensatory drive has decreased.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["41"]
Explanation
Step 1 is to calculate the total units required per hour based on the client's weight
Units per hour = Weight in kg × Dosage (units/kg/hr)
85 × 24 = 2,040 units/hr
Step 2 is to calculate the concentration of the heparin solution in units per mL
Units per mL = Total heparin units ÷ Total volume in mL
25,000 ÷ 500 = 50 units/mL
Step 3 is to calculate the infusion rate in mL per hour
mL/hr = Total units per hour ÷ Units per mL
2,040 ÷ 50 = 40.8
Step 4 is to round to the nearest whole number
40.8 ≈ 41
Answer: 41
Correct Answer is C
Explanation
A. Gown: A moisture-resistant gown is an essential component of contact precautions to prevent the transmission of epidemiologically significant pathogens via direct or indirect contact with the client or environmental surfaces. During tracheostomy care, there is a high risk of being sprayed by secretions, making the gown a mandatory barrier.
B. Goggles: Protective eyewear or goggles are indicated during aerosol-generating procedures, such as tracheostomy care and suctioning, to protect the mucous membranes of the eyes from splashes of respiratory secretions. While not specifically required for "contact" precautions alone, they are necessary for the specific task being performed to ensure the safety of the healthcare worker.
C. N-95 Mask: The precepting nurse must intervene because an N-95 respirator is specifically reserved for airborne precautions, such as in cases of tuberculosis, rubeola, or varicella, to filter out small-particle aerosols. Tracheostomy care and suctioning under contact precautions typically require a standard surgical mask to protect against droplets, but an N-95 is unnecessary and represents an inappropriate use of specialized resources. Using a higher level of respiratory protection than indicated does not align with established hospital infection control protocols.
D. Gloves: Clean, non-sterile gloves are the primary requirement for contact precautions and are used whenever there is potential contact with blood, body fluids, or contaminated surfaces. For tracheostomy care, the nurse may use sterile gloves for the actual procedure, but applying gloves to enter the room is fundamentally correct. Since the nurse is preparing to provide care involving bodily secretions, the use of gloves is an expected and required action that does not warrant intervention.
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