A nurse is caring for a child who has dehydration. Which of the following findings should the nurse expect?
Hct 45%.
Urine specific gravity 1.035.
Capillary refill less than 2 seconds.
Urine output 35 ml/hr.
The Correct Answer is B
Choice A rationale:
Hct 45% (Choice A) refers to the hematocrit level, which measures the proportion of blood volume occupied by red blood cells. While dehydration can lead to elevated hematocrit due to hemoconcentration, a hematocrit value of 45% is within the normal range for both males and females. Dehydration might cause a mild increase, but more significant elevations would be expected in cases of severe dehydration.
Choice B rationale:
Urine specific gravity 1.035 (Choice B) is an indicator of concentrated urine, which is a characteristic finding in dehydration. Dehydration reduces the body's water content, leading to more concentrated urine with higher specific gravity values. A normal range for urine-specific gravity is typically between 1.005 and 1.030.
Choice C rationale:
Capillary refill of less than 2 seconds (Choice C) is not a finding consistent with dehydration. Capillary refill time measures the time it takes for color to return to the nailbed after pressure is applied. Prolonged capillary refill time might indicate poor peripheral perfusion, which can be a sign of dehydration, but a refill time of less than 2 seconds is considered within the normal range.
Choice D rationale:
A urine output of 35 ml/hr (Choice D) is not indicative of dehydration. In fact, a urine output of 35 ml/hr is relatively normal and suggests adequate fluid intake and hydration. Dehydration would typically result in reduced urine output as the body conserves water.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.
Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.
Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.
Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.
Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.
Correct Answer is B
Explanation
Choice A rationale:
Iron 100 mcg/dL The normal range for serum iron levels can vary based on age and gender, but typically, a range of 50 to 150 mcg/dL is considered normal. The provided value of 100 mcg/dL falls within this range and is not a cause for concern. Elevated iron levels can be indicative of hemochromatosis or other disorders, but this value is not concerning.
Choice B rationale:
Hemoglobin 8 g/dL Hemoglobin levels can vary by age and gender, but in general, a hemoglobin level of 8 g/dL is low and suggestive of anemia, a condition characterized by a reduced ability of the blood to carry oxygen. Anemia can lead to fatigue, weakness, and other symptoms, and the nurse should report this finding to the healthcare provider for further evaluation and management.
Choice C rationale:
Sodium 140 mEq/L The normal range for serum sodium levels is typically around 135 to 145 mEq/L. The provided value of 140 mEq/L falls within this normal range and is not a cause for concern. Deviations from this range can indicate various conditions, including dehydration or overhydration, but this value is within an acceptable range.
Choice D rationale:
Calcium 9 mg/dL The normal range for serum calcium levels can vary, but generally, a range of 8.5 to 10.5 mg/dL is considered normal. The provided value of 9 mg/dL falls within this range and is not significantly abnormal. Abnormal calcium levels can be indicative of various conditions, including thyroid disorders or kidney problems, but this value is not concerning.
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