A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Distended jugular veins

Pitting, dependent edema

Decreased blood pressure

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

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Correct Answer is A

Explanation

A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

A. Keep the client's knees in a flexed position while they are in bed. B. Massage the client's legs every 4 hr while they are awake. C. Encourage the client to perform circumduction of the feet. D. Limit the client's fluid intake to 2,000 mL daily.

Correct Answer is C

Explanation

A) Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B) Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C) This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D) Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

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A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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