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 C

Explanation

A) The first 2 min: While it is essential to monitor the client closely during the first few minutes of a PRBC infusion, a two-minute observation period is insufficient to detect most acute transfusion reactions. Many reactions, such as fever, chills, and allergic responses, can take longer to manifest.

B) The final 15 min: Monitoring during the final 15 minutes is important to ensure the infusion is completed without complications. However, the most critical time for monitoring is at the beginning of the infusion, as acute reactions are more likely to occur early on.

C) The first 15 min: The first 15 minutes of a PRBC transfusion are crucial because most acute transfusion reactions, such as allergic reactions, febrile non-hemolytic reactions, and hemolytic reactions, occur within this time frame. The nurse should remain at the bedside to promptly identify and manage any adverse reactions, ensuring the client's safety.

D) The final 2 min: Monitoring during the final two minutes of the infusion is also important, but it is not the critical time frame for detecting most transfusion reactions. Observing the client closely during the initial phase of the transfusion is essential to address any immediate complications.

A. Hyperactive bowel sounds B. muscle weakness C. Increased thirst D. Cerebral edema

Correct Answer is B

Explanation

A) Hyperactive bowel sounds:

Hyperactive bowel sounds are more commonly associated with conditions like diarrhea or gastrointestinal obstruction. Hypokalemia, or low potassium levels, typically affects muscle function rather than bowel activity directly.

B) Muscle weakness:

Muscle weakness is a key manifestation of hypokalemia. Potassium is crucial for muscle function, and a deficiency can lead to significant weakness and fatigue, which is a common symptom in individuals with low potassium levels.

C) Increased thirst:

Increased thirst is more commonly associated with dehydration or hypernatremia rather than hypokalemia. While hypokalemia can cause fluid imbalances, increased thirst is not a primary symptom of low potassium levels.

D) Cerebral edema:

Cerebral edema is not typically associated with hypokalemia. It is more commonly related to conditions such as head injury, infection, or other fluid and electrolyte imbalances. Hypokalemia primarily affects muscle function and heart rhythm.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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