The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?
Urine specific gravity
Serum hematocrit
Pulse rate
Urinary output
The Correct Answer is D
Choice A reason: Urine specific gravity is a measure of the concentration of solutes in the urine. It is inversely related to the hydration status of the client. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration.
Choice B reason: Serum hematocrit is a measure of the percentage of red blood cells in the blood. It is also inversely related to the hydration status of the client. A high serum hematocrit indicates dehydration, while a low serum hematocrit indicates overhydration.
Choice C reason: Pulse rate is a measure of the frequency of the heartbeats. It is directly related to the hydration status of the client. A low pulse rate indicates dehydration, while a high pulse rate indicates overhydration.
Choice D reason: Urinary output is a measure of the amount of urine produced by the kidneys. It is directly related to the hydration status of the client. A low urinary output indicates dehydration, while a high urinary output indicates overhydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Reviewing the advanced directive document is not the priority action. The nurse should first intervene to clear the airway and prevent aspiration of vomitus.
Choice B reason: Elevating the head of the bed 45 degrees is a good practice, but it is not sufficient to relieve the choking. The nurse should also perform suctioning to remove the vomitus from the mouth and throat.
Choice C reason: Performing oropharyngeal suctioning is the best action as it helps to clear the airway and prevent aspiration of vomitus. The nurse should use a Yankauer suction catheter and apply intermittent suction while moving the catheter around the mouth and throat.
Choice D reason: Irrigating the nasogastric tube with water is not appropriate as it may worsen the vomiting and choking. The nurse should stop the enteral feeding and clamp the tube until the client's condition is stabilized.
Correct Answer is D
Explanation
Choice A reason: To avoid pain-causing activity is not the best outcome statement for the nurse to include in this client's plan of care. It does not address the problem of activity intolerance, but rather reinforces the client's refusal to ambulate. It may also delay the client's recovery and increase the risk of complications.
Choice B reason: To take analgesics as prescribed is a relevant outcome statement for the nurse to include in this client's plan of care, but not the best one. It may help to reduce the client's pain and improve his comfort, but it does not directly measure the client's activity tolerance or mobility.
Choice C reason: To show evidence of incision healing is an important outcome statement for the nurse to include in this client's plan of care, but not the best one. It indicates the client's progress and recovery from surgery, but it does not reflect the client's activity intolerance or pain level.
Choice D reason: To ambulate without discomfort is the best outcome statement for the nurse to include in this client's plan of care. It addresses the problem of activity intolerance related to pain, and the goal of increasing the client's mobility and function. It also implies that the client's pain is well-managed and his incision is healing.
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