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 B
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client should avoid alcohol and other substances that can harm the liver, as adalimumab can increase the risk of liver toxicity and hepatitis.
Choice B reason: This is a statement that indicates a need for further teaching. The client should not take naproxen and aspirin as needed for pain relief, as these are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding and gastrointestinal ulcers. Adalimumab can also increase the risk of bleeding and ulcers, as it suppresses the immune system and the inflammatory response.
Choice C reason: This is not a statement that indicates a need for further teaching. The client should report any signs of infection or fever to the doctor, as adalimumab can increase the risk of serious infections and sepsis. Adalimumab can also mask the symptoms of infection, such as inflammation and pain.
Choice D reason: This is not a statement that indicates a need for further teaching. The client should inject the medication under the skin of the abdomen or thigh, as this is the recommended route and site for adalimumab administration.
Correct Answer is D
Explanation
Choice A reason: Slowing the rate to 50 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypovolemic, which is a condition where there is a decreased volume of blood in the body. Hypovolemia can lead to shock, organ failure, and death.
Choice B reason: Slowing the rate to 20 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could also cause the client to become more hypovolemic, which is a serious and life-threatening condition. The nurse should not reduce the IV fluid rate without a physician's order.
Choice C reason: Increasing the rate to 250 mL/hr is not an appropriate action by the nurse before calling the physician to clarify the order. This could cause the client to become more hypervolemic, which is a condition where there is an excess of fluid in the blood vessels. Hypervolemia can cause fluid overload, pulmonary edema, and heart failure.
Choice D reason: Continuing the rate at 125 mL/hr is an appropriate action by the nurse before calling the physician to clarify the order. This is a reasonable rate for a client who has a head injury and hypovolemia, as it can help restore the fluid balance and prevent cerebral edema. The nurse should not change the IV fluid rate without a physician's order.
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