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 ["A","B","D"]
Explanation
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
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.
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