A nurse is collecting data from a patient who has dehydration. Which of the following findings should the nurse expect?
Moist skin
Dark-colored urine
High blood pressure
Distended neck veins
The Correct Answer is B
Choice A reason: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Elderly patients are at a higher risk for dehydration due to physiological changes that come with aging, such as decreased kidney function and physical changes to the body's water balance systems. Additionally, fever increases metabolic rate and fluid loss, and nausea and vomiting prevent adequate fluid intake, further increasing the risk of dehydration.
Choice B: While intentionally limiting fluid intake can lead to dehydration, the body's thirst mechanism in a healthy teenager is typically strong enough to prevent severe dehydration.
Choice C: Diarrhea can certainly lead to dehydration, but a young, otherwise healthy patient typically has a stronger ability to recover from fluid loss than an elderly patient.
Choice D: Infants are at a higher risk for dehydration than older children and adults due to their smaller body weight and higher turnover of water and electrolytes, but in this case, the elderly patient's multiple risk factors put them at a higher risk overall.
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice B reason: Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice C reason: Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction.
Choice D reason: Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.
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