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) Cooked carrots: While cooked carrots do contain some potassium, they are not as rich in potassium as other foods. They are a good source of vitamins and nutrients, but not the most effective option for replenishing potassium levels.

B) Cheddar cheese: Cheese generally contains minimal potassium compared to other foods. It is a good source of calcium and protein, but it is not a significant source of potassium. Individuals on loop diuretics like furosemide, which can cause potassium loss, need to consume foods higher in potassium.

C) Baked potato: Baked potatoes are an excellent source of potassium. A medium-sized baked potato with the skin can provide a significant amount of potassium, which is essential for maintaining normal heart function and muscle contraction. This makes it an ideal food choice for clients on diuretics like furosemide, which can deplete potassium levels.

D) 2% milk: While milk contains potassium, it is not as high in potassium as other foods, like fruits and vegetables. Although it can contribute to daily potassium intake, it is not the most potent source for clients needing to increase their potassium levels due to diuretic use.

A. DSW B. 0.3% NS C. Lactated Ringers D. 0.9% NS

Correct Answer is D

Explanation

A) D5W: Dextrose 5% in water (D5W) is not used with blood transfusions because it can cause hemolysis of the red blood cells due to its hypotonic nature. It can also potentially cause clumping and clotting.

B) 0.3% NS: This is a hypotonic saline solution, which can lead to hemolysis of red blood cells when used as a diluent for blood products. It is not appropriate for use in blood transfusions.

C) Lactated Ringers: Although lactated Ringer's solution is often used for fluid resuscitation, it contains calcium, which can cause clotting in the blood product. Therefore, it is not suitable for use with blood transfusions.

D) 0.9% NS: Normal saline (0.9% sodium chloride) is isotonic and the only solution recommended for use with blood transfusions. It does not cause hemolysis of red blood cells, does not alter the composition of the blood product, and helps to maintain the patency of the IV line. It is the standard diluent used in blood transfusions to ensure the safe administration of blood products.

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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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