The nurse is caring for a client with dehydration with vital signs as follows: blood pressure 96/72, heart rate 106, respiration rate of 18 breaths/minute, and temperature of 101F. After receiving intravenous fluids, which assessment finding is the best way to determine improvement in fluid status?
Blood pressure 115/76 mmHg
Heart rate 106 beats per minute
Temperature to 101° Fahrenheit
Respiratory rate of 18 breaths/min
The Correct Answer is A
A. An increase in blood pressure to 115/76 mmHg indicates improved circulating volume and perfusion, making this the best indicator of fluid status improvement.
B. A heart rate of 106 beats per minute remains elevated (tachycardia), which does not indicate improvement.
C. A temperature of 101°F reflects infection or fever, not hydration status.
D. A respiratory rate of 18 breaths/minute is within normal range but was already normal before fluids, so it is not the best indicator of fluid balance improvement.
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Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Peripheral neuropathy is associated with chronic hyperglycemia, not hypoglycemia. Decreasing insulin would worsen blood glucose control and neuropathy risk.
B. Loss of protective sensation (pain, temperature, pressure) predisposes the client to unnoticed injuries and subsequent infections.
C. As neuropathy progresses, numbness and impaired sensation increase the risk of foot ulcers going unnoticed until they worsen.
D. Peripheral neuropathy is a leading cause of diabetic foot ulcers; it is not limited to vascular disease alone.
E. Chronic hyperglycemia over years damages nerves, leading to neuropathy and increased ulcer risk.
Correct Answer is D
Explanation
A. Hematocrit 38.2% is within the normal range and does not require urgent reporting.
B. Elevated hemoglobin (18.0 g/dL) may indicate hemoconcentration but is not the priority compared to severe anemia.
C. Elevated WBC (17,000) suggests infection or inflammation (common in diverticulitis) but is not immediately life-threatening.
D. A hemoglobin of 6.2 g/dL indicates severe anemia, which can lead to hypoxia, shock, and organ failure. This finding, along with tachycardia and low oxygen saturation, makes it the priority to report for urgent intervention (likely transfusion).
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