A middle-aged adult client with nausea and vomiting for three days presents to the emergency room.
Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Increased heart rate.

Decreased blood pressure.

Increased temperature.

Hypoactive muscle responses.

Alert and oriented.

Answer and Explanation

Correct Answer : A,B

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

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Correct Answer is D

Explanation

Insulin injection sites are rotated to prevent lipodystrophy, which is a condition where the fat tissue under the skin becomes lumpy or dented due to repeated injections.

Lipodystrophy can affect the absorption and effectiveness of insulin.

Choice A is wrong because bruising is not a common complication of insulin

injections. Bruising can occur if the needle hits a blood vessel, but this can be avoided by using a new needle each time and applying gentle pressure after the injection.

Choice B is wrong because infection is not a common complication of insulin

injections. Infection can occur if the skin is not cleaned properly before the injection or if the needle is contaminated, but this can be prevented by washing the hands and using alcohol swabs.

Choice C is wrong because bleeding is not a common complication of insulin

injections. Bleeding can occur if the needle hits a blood vessel, but this can be minimized by using a new needle each time and applying gentle pressure after the injection.

A. The client uses the walker to get up from the chair and looks down at his feet to prevent falling. B. The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. C. The client places her full weight on the walker with her arms while taking steps to prevent pressure on her lower extremity joints. D. The client leans forward at a 60-degree angle while stepping into the walker but looks ahead at where he is going.

Correct Answer is B

Explanation

The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.

Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.

Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.

Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.

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A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Insulin injection sites are rotated to prevent which complication to the tissues?

Correct Answer is D

Explanation

A client with osteoarthritis of the hips and knees has received instructions on how to use a walker for ambulation. Which behavior observed by the nurse indicates the client understands the instructions?

Correct Answer is B

Explanation

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

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The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

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A middle-aged adult client with nausea and vomiting for three days presents to the emergency room.
Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.