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

Bradycardia

Bounding radial pulse

Urine output of 20mL/hr

Cool skin

Answer and Explanation

The Correct Answer is D

A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.

B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.

C. Inspection – Inspection is visual observation, not a tactile assessment.

D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.

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Correct Answer is B

Explanation

A. Bradycardia – Bradycardia is a slow heart rate below 60 beats per minute.

B. Tachycardia – Tachycardia is defined as a heart rate exceeding 100 beats per minute, which can result from fever, stress, dehydration, or cardiac conditions.

C. Dyspnea – Dyspnea refers to difficulty breathing, not an increased heart rate.

D. Tachypnea – Tachypnea is an abnormally rapid respiratory rate, not a rapid heart rate.

A. a complete physical examination B. a medical assessment C. writing nursing orders D. an individualized plan of care

Correct Answer is D

Explanation

A. A complete physical examination – While a physical examination is part of data collection, the primary goal of a nursing assessment is to guide nursing care rather than conduct a full medical examination.

B. A medical assessment – Medical assessments are conducted by physicians to diagnose diseases, while nursing assessments focus on holistic patient care.

C. Writing nursing orders – Nursing orders are based on the care plan but do not encompass the entire purpose of the assessment.

D. An individualized plan of care – The primary purpose of a nursing assessment is to collect data to create a care plan tailored to the patient's specific needs.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An abnormally rapid heart rate above 100 beats per minute is called:

Correct Answer is B

Explanation

A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for:

Correct Answer is D

Explanation

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