The nurse is caring for a client who is dehydrated. Which action by the nurse is the best assessment of the client's hydration status?

Measure the blood pressure.

Take the client's temperature.

Obtain the client's weight.

Count the pulse rate.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Measure the blood pressure: Blood pressure can provide information about perfusion and potential hypotension due to dehydration, but it is influenced by many factors and may not accurately reflect changes in fluid volume alone.

B. Take the client's temperature: Temperature assessment is important for detecting fever or infection but does not directly measure hydration status. It offers limited information regarding fluid balance.

C. Obtain the client's weight: Daily weights are the most reliable indicator of fluid status, as changes in body weight reflect fluid loss or gain. Monitoring weight trends allows for accurate assessment of dehydration or fluid replacement efficacy.

D. Count the pulse rate: Heart rate may increase with dehydration due to compensatory mechanisms, but it is nonspecific and can be influenced by medications, activity, or anxiety, making it less accurate than weight measurement for assessing hydration.

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Correct Answer is C

Explanation

Rationale:
A. Sodium level 140 mEq/L (140 mmol/L): This value is within the normal reference range and is unlikely to contribute to the development of a dysrhythmia. Sodium imbalances can affect cardiac function, but this level does not pose a risk.

B. Potassium level 3.8 mg/dL (3.8 mmol/L): Potassium is within the normal range (3.5–5.0 mEq/L) and would not typically precipitate a cardiac dysrhythmia. Hypokalemia or hyperkalemia outside of the normal range would be more concerning.

C. Calcium level 7.2 mg/dL (1.8 mmol/L): This value is below the normal range (8.4–10.6 mg/dL), indicating hypocalcemia. Low calcium levels can prolong the QT interval and increase the risk of ventricular dysrhythmias, making this the most likely contributing factor to the telemetry changes.

D. Oxygen saturation level 97%: This oxygen saturation is within the normal range and does not contribute to cardiac dysrhythmias. Adequate oxygenation reduces, rather than exacerbates, the risk of arrhythmias.

A. Measure abdominal girth. B. Observe for flushing. C. Auscultate breath sounds. D. Obtain current vital signs.

Correct Answer is D

Explanation

A. Measure abdominal girth: While this can detect abdominal distention or internal bleeding, it is not the immediate priority compared to assessing hemodynamic stability.

B. Observe for flushing: Flushing is not directly related to gastrointestinal bleeding and does not provide critical information about the client’s immediate risk.

C. Auscultate breath sounds: Although important for overall assessment, respiratory status is not the most urgent concern in a client with potential upper GI bleeding compared to monitoring for shock.

D. Obtain current vital signs: Coffee-ground emesis indicates possible upper gastrointestinal bleeding. The priority is to assess hemodynamic status, including blood pressure and heart rate, to determine if the client is experiencing hypovolemia or shock, which requires immediate intervention.

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The nurse is caring for a client who is dehydrated. Which action by the nurse is the best assessment of the client's hydration status?

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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