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. Dry, sticky mucous membranes are associated with dehydration, not low calcium levels.
B. Muscle tremors are a potential manifestation of hypocalcemia.
C. Polyuria is not typically associated with low calcium levels.
D. Chvostek's sign is a facial twitching that can be associated with hypocalcemia; a negative Chvostek's sign would not be expected in this case.

A. Use blood that is less than a month old. B. Use an 18-gauge needle to obtain venous access. C. Obtain the client’s vital signs every 30 min throughout the transfusion. D. Administer each unit over 3 hr.

Correct Answer is C

Explanation

A. While using fresher blood is desirable, it is not always practical, and the primary consideration is the client's clinical condition.
B. An 18-gauge needle may be used for rapid infusion, but the size of the needle should be appropriate for the client's condition and the facility's policy.
C. Monitoring vital signs is essential during a blood transfusion to detect any potential adverse reactions promptly.
D. Administering blood units over a recommended time frame is important, but obtaining vital signs at regular intervals during the transfusion is a more immediate and continuous monitoring method.

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

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Naxlex Comprehensive Predictor Exams

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