A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Blood pressure 178/90 mm Hg

Edema

Bounding bilateral pulses

Increased urine specific gravity

Answer and Explanation

The Correct Answer is D

A) Blood pressure 178/90 mm Hg: Elevated blood pressure is more commonly associated with fluid overload or hypertension rather than dehydration. In dehydration, one would expect to see a decrease in blood pressure, particularly orthostatic hypotension, due to a reduction in blood volume.

B) Edema: Edema indicates fluid retention in the tissues, which is a sign of fluid overload rather than dehydration. Dehydration typically results in reduced extracellular fluid volume, leading to symptoms like dry mucous membranes and poor skin turgor, rather than swelling.

C) Bounding bilateral pulses: Bounding pulses are usually seen in conditions of increased cardiac output or fluid overload, where there is an excess of fluid volume. In contrast, dehydration often leads to weak and thready pulses due to decreased circulatory volume.

D) Increased urine specific gravity: Increased urine specific gravity is a direct indicator of dehydration. It occurs because the kidneys concentrate urine to conserve water, leading to a higher concentration of solutes in the urine. This is a reliable clinical marker of reduced hydration status, reflecting the body's attempt to maintain fluid balance by conserving water.

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Correct Answer is A

Explanation

A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.

B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.

C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.

D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature

A. Isotonic solution B. Total Parenteral Nutrition (TPN) C. Hypertonic solution D. Hypotonic solution

Correct Answer is D

Explanation

A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, are used to maintain fluid balance and are not ideal for treating hypernatremia. They do not correct the elevated sodium levels and might even contribute to fluid overload.

B) Total Parenteral Nutrition (TPN): TPN is a form of nutrition provided intravenously and is not specifically used to manage electrolyte imbalances like hypernatremia. It is used for clients who cannot eat or absorb nutrients through the gastrointestinal tract.

C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, are used to treat hyponatremia or other conditions requiring increased sodium concentration. They would exacerbate hypernatremia rather than treat it.

D) Hypotonic solution: Hypotonic solutions, such as 0.45% sodium chloride (half-normal saline) or dextrose 5% in water (D5W), are appropriate for treating hypernatremia. These solutions help dilute the excess sodium in the blood, reduce serum sodium levels, and facilitate a gradual correction of the imbalance.

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A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?

Correct Answer is A

Explanation

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy. Which solution should the nurse prepare to infuse for this client?

Correct Answer is D

Explanation

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