A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Urine output 20 mL/hr

Bradycardia

Sodium 142 mEq/L

Cool skin

Answer and Explanation

The Correct Answer is A

A. Urine output 20 mL/hr: Oliguria, or low urine output (less than 30 mL/hr), is a common sign of dehydration.
B. Bradycardia: Dehydration typically causes tachycardia (increased heart rate) as the body compensates for decreased blood volume.
C. Sodium 142 mEq/L: A sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) and does not indicate dehydration.
D. Cool skin: Dehydration usually results in warm, dry skin due to decreased perfusion and sweating.

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Correct Answer is D

Explanation

36. A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?
A. Constipation
B. Hyporeflexia
C. Increased appetite
D. Headache
Correct answer:
A. Constipation
• Rationale: Constipation is not a common symptom of hyponatremia (low sodium levels).
B. Hyporeflexia
• Rationale: Hyponatremia can cause neuromuscular symptoms, but hyporeflexia (reduced reflexes) is not typically one of them. Hyperreflexia (increased reflexes) is more common.
C. Increased appetite
• Rationale: Increased appetite is not associated with hyponatremia. Symptoms usually relate to neurological and gastrointestinal systems.
D. Headache
• Rationale: Headache is a common symptom of hyponatremia due to cellular swelling and increased intracranial pressure.

A. Allow the client to expel some fluid before continuing. B. Encourage the client to bear down. C. Stop the enema and document that the client did not tolerate the procedure. D. Lower the height of the solution container.

Correct Answer is D

Explanation

A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.

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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is D

Explanation

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