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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Aspiration is not a common complication of TPN. TPN is administered intravenously, bypassing the gastrointestinal tract, which reduces the risk of aspiration. Choice B rationale
Polyuria, or excessive urination, is not typically a direct complication of TPN. However, the fluid balance of patients on TPN should be monitored, as both overhydration and dehydration can lead to urinary changes.
Choice C rationale
Stomatitis, or inflammation of the mouth and lips, is not a common complication of TPN. Since TPN bypasses the gastrointestinal tract, it does not typically cause oral complications.
Choice D rationale
Abdominal distention can occur as a complication of TPN. This is because TPN can cause an imbalance in the gut flora, leading to gas production and bloating. Additionally, if a patient on TPN has an underlying condition that affects gut motility, they may experience abdominal distention.
Correct Answer is A
Explanation
Choice A rationale
Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.
Choice B rationale
Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice C rationale
Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice D rationale
Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.
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