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: This is not a correct finding for hypovolemia. Peripheral edema is the swelling of the extremities due to fluid accumulation in the interstitial spaces. It is a sign of fluid volume excess, not fluid volume deficit.
Choice B reason: This is not a correct finding for hypovolemia. Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a typical sign of fluid volume deficit, as the heart rate usually increases to compensate for the low blood pressure and low cardiac output.
Choice C reason: This is not a correct finding for hypovolemia. Hypertension is a high blood pressure, usually above 140/90 mmHg. It is not a typical sign of fluid volume deficit, as the blood pressure usually decreases due to the reduced blood volume and vascular resistance.
Choice D reason: This is a correct finding for hypovolemia. Decreased urine output is a sign of fluid volume deficit, as the kidneys try to conserve water and electrolytes by reducing the urine production. The normal urine output is about 30 mL per hour, and anything below 20 mL per hour is considered oliguria, which indicates impaired renal function.
Correct Answer is A
Explanation
Choice A reason: Sudden abdominal pain is a sign of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. It occurs when the ulcer erodes through the wall of the stomach or duodenum, causing leakage of gastric contents into the peritoneal cavity. This causes inflammation, infection, and peritonitis.
Choice B reason: Hyperactive bowel sounds are not indicative of gastrointestinal perforation. They may be present in other conditions, such as gastroenteritis, intestinal obstruction, or diarrhea.
Choice C reason: Bradycardia is not indicative of gastrointestinal perforation. It may be caused by other factors, such as vagal stimulation, medication side effects, or cardiac disorders.
Choice D reason: Decreased blood pressure is not indicative of gastrointestinal perforation. It may be a result of other causes, such as hypovolemia, shock, or dehydration.
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