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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client with Parkinson’s disease who urgently needs to use the bathroom is at high risk for falls due to rigidity, tremors, and shuffling gait. Needing to move quickly to the bathroom further increases the risk of injury, making this the priority for immediate assessment and assistance.
B. Refusing bisphosphonate therapy for osteoporosis is important to address but does not present an immediate safety risk requiring urgent assessment.
C. A client who is 3 days post–hip fracture surgery requires ongoing monitoring, but this is expected care and not an immediate fall or injury risk compared with the Parkinson’s client.
D. An older adult ambulating may need monitoring for safety, but unless new symptoms arise, this does not pose the same level of urgency as the Parkinson’s client who needs urgent toileting.
Correct Answer is B
Explanation
A. A urine output of 750 mL/24 hr is low (oliguria) but not immediately life-threatening compared to electrolyte imbalances.
B. A potassium level of 5.2 mEq/L is slightly above normal and indicates hyperkalemia risk, which can progress rapidly to life-threatening cardiac dysrhythmias. This client is the highest priority for immediate assessment and intervention.
C. Depression is important but not the immediate priority in an acute setting compared to unstable lab values.
D. A scheduled dialysis client may be stable until treatment; the elevated potassium requires faster intervention.
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