A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?

Urine output 200 mL/4 hr.

Heart rate 104/min.

Peripheral pulses +1.

Urine specific gravity 1.04. .

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.

Choice B rationale:

A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.

Choice C rationale:

Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.

Choice D rationale:

A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale:

Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.

Choice B rationale:

Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.

Choice C rationale:

Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.

Choice D rationale:

Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.

Choice E rationale:

Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.

A. Extreme thirst. B. Weak, irregular pulse. C. Hyperactive bowel sounds. D. Hyperactive reflexes.

Correct Answer is B

Explanation

Choice A rationale:

Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.

Choice B rationale:

"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.

Choice C rationale:

Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.

Choice D rationale:

Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.

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A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.Which of the following findings should the nurse identify as effectiveness of the treatment?

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A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?