A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Dark-colored urine

High blood pressure

Distended neck veins

Moist skin

Answer and Explanation

The Correct Answer is A

A.   Dark-colored urine is a common finding in dehydration, indicating concentrated urine.
B.   Dehydration is more likely to be associated with hypotension rather than high blood pressure.
C.   Distended neck veins are more associated with fluid overload, not dehydration.
D.   Moist skin is not a typical finding in dehydration; dry skin is more common.

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Correct Answer is B

Explanation

A. While cold packs might be used for certain conditions, measuring the circumference of both upper arms is the priority in this situation.
B. Swelling of the arm above the PICC insertion site can indicate a complication such as thrombophlebitis, which is inflammation and clotting of the vein. The nurse should measure the circumference of both upper arms and compare them to detect any difference in size, which can indicate edema due to impaired venous return. This is the first action the nurse should take because it is an assessment step that can provide objective data to guide further interventions.
C. Swelling above the PICC insertion site could indicate complications such as infiltration, and the provider needs to be informed promptly. However, the nurse should first measure the circumference of both upper arms first.
D. Removing the PICC line should be done under the guidance of a healthcare provider, and it is not the first action to take.

A. Client has an NG tube to gastric suction. B. Client reports drinking 3.5 to 4 L of water each day. C. Client has a history of alcohol abuse disorder, D. Client is currently prescribed spironolactone

Correct Answer is A

Explanation

A. Hypokalemia can be caused by excessive loss of potassium from the gastrointestinal tract, such as from vomiting, diarrhea, or gastric suction.
B. Drinking a large amount of water is more likely to dilute sodium levels rather than potassium.
C. Alcohol abuse disorder is not a direct cause of low potassium levels.
D. Spironolactone is a potassium-sparing diuretic, and its use can lead to hyperkalemia, not hypokalemia.

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A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

Correct Answer is A

Explanation

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