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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
For this scenario, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.
Plugging in the numbers: (100 mL × 60 gtt/mL) / 60 min = 6000 gtt / 60 min = 100 gtt/min.
Therefore, the nurse should set the IV flow rate to deliver 100 drops per minute.
Correct Answer is A
Explanation
A. This statement demonstrates an understanding that consuming yogurt can potentially help reduce the odor associated with gas. Yogurt contains probiotics, which can promote digestive health and possibly reduce the intensity of gas odors. This is a reasonable approach for managing symptoms related to colostomy.
B. Carbonated beverages are not typically recommended for controlling odor related to a colostomy. In fact, carbonated drinks can sometimes increase gas production and may exacerbate gas-related symptoms. Therefore, this statement does not indicate an appropriate understanding of dietary management for a colostomy.
C. Pasta and other starchy foods like rice and bread are generally well-tolerated and can help thicken stool consistency, which may be beneficial for individuals with a colostomy. Therefore, eliminating pasta from the diet is not necessary and does not reflect an accurate understanding of dietary recommendations post-colostomy.
D. Distributing meals evenly throughout the day is generally recommended to promote balanced nutrition and manage digestion. There is no specific requirement that the largest meal must be in the evening. This statement does not directly relate to dietary management specific to colostomy care.
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