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. After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B. The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C. There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D. While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

A. A client who has lactose intolerance B. A client who has had a stroke C. A client who has had prolonged diarrhea D. A client who is 4 hr postoperative following a leg amputation under general anesthesia E. A client who has had radiation therapy for head and neck cancer

Correct Answer is ["B","D","E"]

Explanation

A. Lactose intolerance does not directly increase the risk of aspiration. It is a condition where the body cannot easily digest lactose, a type of sugar found in dairy products, leading to gastrointestinal symptoms such as bloating, diarrhea, and gas. Aspiration risk is not typically associated with lactose intolerance.
B. Clients who have had a stroke often experience dysphagia (difficulty swallowing) due to impaired coordination of the muscles involved in swallowing. This dysphagia can lead to food or liquids entering the airway instead of the esophagus, increasing the risk of aspiration.
C. Prolonged diarrhea does not directly increase the risk of aspiration during eating. Diarrhea is a gastrointestinal symptom that typically affects the lower digestive tract and is not directly related to swallowing or aspiration risk.
D. After surgery, especially under general anesthesia, clients may have impaired protective airway reflexes and reduced consciousness level, increasing the risk of aspiration. The recovery phase postoperatively is critical, as clients may not have regained full control of their swallowing reflexes.
E. Radiation therapy in the head and neck region can cause tissue damage, including to the muscles and nerves involved in swallowing. This damage can result in dysphagia and increase the risk of aspiration during eating.

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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

A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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