A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following manifestations of dehydration?
A client who has a urine specific gravity of 1.010. (Reference Range 1.005-1.030)
A client who has a hematocrit of 42%. (Reference Range 36-46%)
A client who has a temperature of 39 °C.
A client who has a weight loss of 2.2 kg in 24 hr.
The Correct Answer is D
Choice A reason: A client who has a urine specific gravity of 1.010 is not dehydrated. Urine specific gravity is a measure of the concentration of solutes in the urine. A normal range is 1.005-1.030, which means that the urine is neither too dilute nor too concentrated. A high urine specific gravity (>1.030) indicates dehydration, as the urine becomes more concentrated due to fluid loss. A low urine specific gravity (<1.005) indicates overhydration, as the urine becomes more dilute due to fluid excess.
Choice B reason: A client who has a hematocrit of 42% is not dehydrated. Hematocrit is the percentage of red blood cells in the blood. A normal range is 36-46% for women and 40-54% for men. A high hematocrit (>54% for men and >46% for women) indicates dehydration, as the blood becomes more viscous due to fluid loss. A low hematocrit (<40% for men and <36% for women) indicates overhydration, as the blood becomes more diluted due to fluid excess.
Choice C reason: A client who has a temperature of 39 °C may or may not be dehydrated. Temperature is a measure of the body's heat production and regulation. A normal range is 36.5-37.5 °C. A high temperature (>37.5 °C) indicates fever, which can be caused by various factors, such as infection, inflammation, or medication. Fever can also cause dehydration, as the body loses fluid through sweating and increased respiration. However, fever is not a specific sign of dehydration, as there may be other causes or contributing factors.
Choice D reason: A client who has a weight loss of 2.2 kg in 24 hr is dehydrated. Weight loss is a measure of the change in the body's mass over time. A normal range is 0.5-1 kg per week. A rapid weight loss (>1 kg per day) indicates dehydration, as the body loses fluid through various routes, such as urine, stool, sweat, or vomit. Weight loss is a sensitive and reliable sign of dehydration, as it reflects the amount of fluid loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Mental alertness is not affected by the administration of hypertonic solutions. Hypertonic solutions are fluids that have a higher concentration of solutes than the blood. They draw water out of the cells and into the blood vessels, increasing the blood volume and osmolarity.
Choice B reason: Decreased pulse is not a result of administering hypertonic solutions too quickly. On the contrary, hypertonic solutions can increase the pulse rate as they increase the blood volume and pressure.
Choice C reason: Decreased blood pressure is not a consequence of administering hypertonic solutions too quickly. Hypertonic solutions can raise the blood pressure as they increase the blood volume and osmolarity.
Choice D reason: Fluid overload is the correct answer. Administering hypertonic solutions too quickly can cause fluid overload, which is a condition where the body has too much fluid in the blood vessels. This can lead to symptoms such as edema, dyspnea, crackles, and weight gain. Fluid overload can also cause heart failure, pulmonary edema, and cerebral edema.
Correct Answer is D
Explanation
Choice A reason: This is not a correct statement because these medications do not coat the ulcer. They are not antacids or mucosal protectants, which can form a protective layer over the ulcer and neutralize the stomach acid.
Choice B reason: This is not a correct statement because these medications do not stop the acid production. They only reduce it by inhibiting the proton pump, which is responsible for secreting acid into the stomach.
Choice C reason: This is not a correct statement because these medications should be taken as prescribed, not as needed. They are not analgesics or anti-inflammatory drugs, which can relieve the pain and inflammation of the ulcer.
Choice D reason: This is a correct statement because these medications have two effects: they kill the bacteria that cause the infection and inflammation of the ulcer, and they reduce the acid production that aggravates the ulcer. This can help heal the ulcer and prevent complications.
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