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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.

Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.

Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.

Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.

A. 0.9% sodium chloride B. Dextrose 5% in water C. Lactated Ringer's D. Dextrose 5% in 0.45% sodium chloride

Correct Answer is A

Explanation

Choice A reason: 0.9% sodium chloride or normal saline is the only solution that should be administered with PRBCs, as it has an isotonic osmolarity and pH that are compatible with blood products and can prevent hemolysis or clotting.

Choice B reason: Dextrose 5% in water or D5W should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.

Choice C reason: Lactated Ringer's or LR should not be administered with PRBCs, as it contains calcium and lactate that can interfere with blood coagulation and cause clotting or embolism.

Choice D reason: Dextrose 5% in 0.45% sodium chloride or D5½NS should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.

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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?

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