A nurse in a long-term care facility is collecting data from an older adult client. Which of the following findings indicates that the client might be dehydrated?
Recent onset of confusion
Cool, clammy skin
Decrease in pulse rate
Increase in blood pressure
The Correct Answer is A
Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.
Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.
Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.
Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: BUN or blood urea nitrogen 30 mg/dL is above the normal range of 10 to 20 mg/dL and indicates renal impairment or dehydration, which can be caused by contrast dye used during coronary angiography or blood loss during or after the procedure. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice B reason: Sinus rhythm 95/min on a cardiac monitor is within the normal range of 60 to 100/min and does not indicate any cardiac arrhythmia or ischemia.
Choice C reason: Respiratory rate 12/min is within the normal range of 12 to 20/min and does not indicate any respiratory distress or hypoxia.
Choice D reason: PTT or partial thromboplastin time 25 seconds is within the normal range of 25 to 35 seconds and does not indicate any bleeding disorder or anticoagulant therapy.
Correct Answer is D
Explanation
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
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