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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?

A.

Skin tenting

B.

BP 178/90 mm Hg

C.

Red mucous membranes

D.

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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Related Questions

Correct Answer is A

Explanation

A. Clean gloves should be worn when entering the room of a client with MRSA to prevent contact transmission of the bacteria. Gloves should be put on before any contact with the client or potentially contaminated surfaces and should be removed and disposed of properly after leaving the room.
B. A surgical mask is generally not necessary for routine care of a client with MRSA unless there is a risk of splashes or sprays of bodily fluids. The main mode of transmission for MRSA is contact, so gloves are the primary protective measure.
C. Sterile gloves are typically not required unless performing sterile procedures directly involving the wound or handling sterile equipment. For routine assessment of the client's pulse, clean gloves are sufficient.
D. Protective eyewear is not necessary for routine care such as checking a client's pulse. It is primarily used when there is a risk of splashes or sprays that could potentially reach the eyes.

Correct Answer is A

Explanation

A. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

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