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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This is not a correct answer because intracorporeal lithotripsy is a procedure that uses a laser or an ultrasonic probe to break up gallstones inside the gallbladder or the bile ducts. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder.

Choice B reason: This is a correct answer because laparoscopic cholecystectomy is a surgery that removes the gallbladder through small incisions in the abdomen. It is the preferred treatment for cholecystitis, as it eliminates the source of inflammation and prevents further complications.

Choice C reason: This is not a correct answer because extracorporeal shock wave lithotripsy (ESWL) is a procedure that uses shock waves to break up gallstones outside the body. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may not be effective for all types of gallstones.

Choice D reason: This is not a correct answer because methyl tertiary butyl ether (MTBE) infusion is a procedure that uses a chemical solvent to dissolve gallstones inside the gallbladder. It is not a preferred treatment for cholecystitis, as it does not remove the inflamed gallbladder and may cause side effects such as nausea, vomiting, and liver damage.

A. The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate. B. Your appendix doesn't play a major role so you won't notice any difference after your recovery from surgery. C. Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this. D. Your small intestine will adapt over time to the absence of your appendix.

Correct Answer is D

Explanation

Choice A reason: This statement is not the best response for the nurse to give. The surgeon will not encourage the client to limit their fat intake after an appendectomy, as this has nothing to do with the appendix. The appendix is a small pouch attached to the beginning of the large intestine, not the small intestine where most of the fat digestion and absorption occurs.

Choice B reason: This statement is not the best response for the nurse to give. The appendix does play a role in the immune system and the gut microbiome, as it contains lymphoid tissue and beneficial bacteria. The client may notice some changes in their immunity or digestion after an appendectomy, especially if they have an infection or take antibiotics.

Choice C reason: This statement is not the best response for the nurse to give. The appendix does not affect the absorption of nutrients from the food the client eats, as it is not involved in the digestive process. The appendix is located at the end of the small intestine, where most of the nutrients have already been absorbed.

Choice D reason: This statement is the best response for the nurse to give. The appendix is not essential for survival, and the small intestine can adapt to its removal over time. The client may experience some temporary symptoms such as diarrhea, bloating, or gas after an appendectomy, but these usually resolve within a few weeks. The nurse should reassure the client that they can live a normal and healthy life without an appendix.

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A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following manifestations of dehydration?

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Naxlex Comprehensive Predictor Exams

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo which preferred treatment?

Correct Answer is B

Explanation

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

Correct Answer is D

Explanation

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