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 C

Explanation

A. Glucagon is administered to increase blood glucose levels in hypoglycemic states. However, the client's glucose level is within the normal range (72 mg/dL), so administering glucagon is not appropriate.

B. Chvostek's sign is assessed to detect hypocalcemia, not hypokalemia. It involves tapping the facial nerve anterior to the earlobe and observing for facial muscle contraction. This action is not relevant to the potassium level and is not indicated based on the laboratory findings provided.
C. The client's potassium level of 3.0 mEq/L is below the normal range, indicating hypokalemia. Potassium replacement is essential to prevent complications such as cardiac arrhythmias. The nurse should follow the facility's protocol for administering potassium replacement, which may include adjusting the TPN solution or administering intravenous potassium supplements.
D. Discontinuing the TPN infusion is not warranted based solely on the potassium level. The TPN infusion provides essential nutrition and should not be stopped without addressing the electrolyte imbalance separately.

A. Wear gloves when entering the client's room. B. Encourage the client to ambulate in the hall. C. Wear an N95 respirator mask. D. Provide a positive pressure airflow room.

Correct Answer is C

Explanation

A. Gloves are not specifically required for airborne precautions unless contact with infectious secretions or materials is anticipated. Airborne precautions primarily focus on preventing inhalation of infectious droplet nuclei. Therefore, wearing gloves is not necessary solely due to airborne precautions.
B. This option is not related to airborne precautions. Encouraging ambulation in the hall is a general nursing intervention and does not specifically address preventing the transmission of airborne pathogens.
C. An N95 respirator mask is designed to filter out 95% of airborne particles, including those containing infectious agents. It provides respiratory protection for healthcare workers who may be exposed to airborne pathogens during procedures such as aerosol-generating procedures (e.g., suctioning, bronchoscopy) or when caring for clients with airborne infections.
D. Positive pressure airflow rooms are typically used for clients requiring protective isolation (e.g., immunocompromised clients) but are not specifically required for clients on airborne precautions. Negative pressure airflow rooms are preferred for clients on airborne precautions because they prevent the spread of airborne pathogens to other areas of the facility.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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