A nurse is collecting data from a patient who has dehydration.
What findings should the nurse expect?
Dark-colored urine.
High blood pressure.
Distended neck veins.
Moist skin.
Moist skin.
The Correct Answer is A
Choice A rationale
Dark-colored urine is a common symptom of dehydration. When a person is dehydrated, their kidneys try to conserve water by concentrating the urine, which can make it appear darker. Choice B rationale
High blood pressure is not typically associated with dehydration. In fact, dehydration can sometimes lead to low blood pressure due to a decrease in blood volume.
Choice C rationale
Distended neck veins are not typically a symptom of dehydration. They are more commonly associated with conditions that cause fluid overload, such as heart failure.
Choice D rationale
Moist skin is not typically a symptom of dehydration. In fact, one of the symptoms of severe dehydration can be dry, cool skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea.The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance.It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance.Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed.This step is critical to prevent complications from severe diarrhea.
Correct Answer is B
Explanation
Choice A rationale
Unplugging the cord by holding the plug is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice B rationale
Ensuring the plug has three prongs is the most important action to prevent electrical hazards when administering intravenous fluids. A three-prong plug is grounded and reduces the risk of electrical shock.
Choice C rationale
Avoiding rolling equipment over extension cords is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice D rationale
Plugging in the pump close to the socket is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
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