A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)
Hypotension
Bradycardia
Pale yellow urine
Poor skin turgor
Flat neck veins
Correct Answer : A,D,E
A. Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B. Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C. Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D. Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E. Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.
Choice B rationale
Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.
Choice C rationale
Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.
Choice D rationale
Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.
Correct Answer is C
Explanation
Choice A rationale
A sodium level of 165 mEq/L is higher than the normal range and could indicate that the body is still dehydrated.
Choice B rationale
A hematocrit of 62.5 is higher than the normal range and could suggest that the body is still dehydrated.
Choice C rationale
A urine specific gravity of 1.020 is within the normal range and suggests that the body is rehydrating effectively.
Choice D rationale
A potassium level of 3.2 mEq/L is lower than the normal range and could suggest that the body’s electrolyte balance has not yet been restored.
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