A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

Skin tenting

BP 178/90 mm Hg

Red mucous membranes

Jugular vein distention

Answer and Explanation

The Correct Answer is A

A.   Skin tenting occurs when the skin loses its elasticity due to dehydration. When gently pinched, the skin may remain elevated and return to its normal position slowly. This finding is a classic sign of dehydration and indicates that the client has lost significant fluid volume.
B.   Elevated blood pressure (BP) can sometimes be associated with dehydration, especially in acute cases or when there are underlying conditions like hypovolemia. However, it is not typically a primary indicator of dehydration. Hypotension (low blood pressure) is more commonly associated with severe dehydration.
C.   Red mucous membranes may indicate various conditions, including dehydration. Dehydration can lead to dryness and mucosal irritation, resulting in redness. However, red mucous membranes alone are not specific enough to reliably indicate dehydration without considering other signs and symptoms.

D.   Jugular vein distention (JVD) is associated with fluid overload rather than dehydration. It occurs when there is increased pressure in the venous system, often due to heart failure or fluid retention. JVD is not typically seen in dehydrated individuals.

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Correct Answer is A

Explanation

A. This option is aimed at modifying the consistency of fluids to make them easier to swallow for someone with dysphagia. Thickened liquids are often recommended to prevent aspiration (when food or liquid enters the airway instead of the esophagus) in patients with swallowing difficulties.
B. Placing food on the unaffected side of the mouth, which would be the right side in the case of left-sided weakness, is recommended to aid in easier chewing and swallowing.
C. Temperature can affect how easily food can be swallowed and enjoyed by someone with dysphagia. Extremely hot or cold foods can be more challenging to swallow. However, this dose not address the risk of aspiration.
D. Tipping the head back during swallowing is not recommended because it can increase the risk of choking or aspiration. Instead of tilting the head back, clients with dysphagia should be instructed to maintain an upright position when eating and drinking.

A. Malnutrition B. Multiple caregivers C. Urinary catheterization D. Chlorhexidine washes

Correct Answer is C

Explanation

A. Malnutrition itself is not a direct cause of healthcare-associated infections (HAIs).
B. While having multiple caregivers can potentially increase the risk of transmission of infections if proper hand hygiene and infection control practices are not followed, it is not a direct cause of HAIs. Proper adherence to infection control protocols mitigates this risk.
C. Urinary catheterization is a common cause of healthcare-associated infections, particularly urinary tract infections (UTIs). Catheters provide a pathway for bacteria to enter the urinary tract, leading to infection if not managed properly or if left in place longer than necessary.
D. Chlorhexidine washes are actually used as an infection prevention measure rather than a cause of HAIs. Chlorhexidine is an antiseptic agent that is effective against a wide range of microorganisms and is used for preoperative skin cleansing, central line care, and other procedures to reduce the risk of infections.

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A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

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