A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

(Select All that Apply.)

Bradycardia

Pale Yellow Urine

Poor Skin Turgor

Hypotension

Flat Neck Veins

Answer and Explanation

Correct Answer : C,D,E

A. Bradycardia: Vomiting and diarrhea usually lead to tachycardia (increased heart rate) as the body compensates for hypovolemia, not bradycardia (slow heart rate).

B. Pale Yellow Urine: Dehydration often causes the urine to become concentrated and dark yellow, not pale yellow.

C. Poor Skin Turgor: Poor skin turgor is a classic sign of dehydration caused by fluid loss.

D. Hypotension: Loss of fluid volume can result in hypotension due to reduced blood circulation.

E. Flat Neck Veins: Dehydration causes reduced venous return, leading to flat neck veins, particularly when lying down.

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Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

A. Hematocrit 45% (37% to 52%) B. Creatinine 0.9 mg/dL (0.5-1.2 mg/dL) C. BUN 25 mg/dL (10-20 mg/dL) D. Urine specific gravity 1.028 (1.005 to 1.030)

Correct Answer is C

Explanation

A. Hematocrit 45% (37% to 52%): This value is within the normal range for hematocrit. Dehydration may increase the hematocrit due to a relative increase in red blood cell concentration, but 45% is still within normal limits.

B. Creatinine 0.9 mg/dL (0.5-1.2 mg/dL): This value is within the normal range for creatinine, indicating normal kidney function.

C. BUN 25 mg/dL (10-20 mg/dL): An elevated BUN level is a sign of dehydration as it reflects increased protein breakdown and decreased renal perfusion. This value is above the normal range and should be reported to the provider.

D. Urine specific gravity 1.028 (1.005 to 1.030): This value is within the normal range and indicates that the kidneys are concentrating urine, which is typical in dehydration as the body tries to conserve water.

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A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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