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 B

Explanation

A. Urinary frequency refers to the need to urinate more often than usual. It does not typically cause changes in the color, clarity, or odor of urine. It may be associated with conditions like urinary tract infections (UTIs) or other urinary issues but does not directly cause dark amber, cloudy, or foul-smelling urine.
B. A UTI is a common cause of changes in urine characteristics. Dark amber color can indicate concentrated urine due to dehydration or the presence of blood. Cloudiness suggests the presence of pus or bacteria, while an unpleasant odor can be due to bacterial growth. UTIs often cause these symptoms due to inflammation and infection of the urinary tract.
C. Urinary incontinence refers to involuntary loss of urine. It does not typically cause changes in the appearance or odor of urine unless it leads to urine pooling and subsequent bacterial growth, which could potentially cause odor. However, incontinence itself is not a direct cause of dark amber, cloudy urine with an unpleasant odor.
D. Urinary retention occurs when the bladder does not empty completely or at all. It can lead to concentrated urine (dark amber color) due to prolonged storage in the bladder. Cloudiness and an unpleasant odor can occur if there is bacterial growth in stagnant urine. Therefore, urinary retention can contribute to the observed urine characteristics.

A. The nurse allows the client to rest in a supine position during feeding. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.

Correct Answer is A

Explanation

A. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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