A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Distended neck veins

Bounding pulse

BP 146/94 mm Hg

Urine specific gravity 1.034 .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.

In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.

It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.

Choice B rationale:

A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.

A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.

Choice C rationale:

A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:

Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.

A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.

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Correct Answer is B

Explanation

Choice A rationale:

Incorrect. Patients have a legal right to access their medical records under the Health Information Portability and Accountability Act (HIPAA). Denying access is a violation of patient rights and could lead to legal consequences.

Undermines patient autonomy and trust. Patients have a right to know what information is in their medical records and to participate in their own healthcare decisions. Denying access can erode trust in the healthcare system.

Potential for errors and misunderstandings. If patients cannot review their records, they may not be able to identify errors or misunderstandings that could impact their care.

Choice B rationale:

Correct. This response upholds patient rights while ensuring that the request for access is documented and handled appropriately.

Protects patient privacy and confidentiality. The written request process helps to ensure that only the patient or their authorized representative has access to the records.

Provides a mechanism for tracking and auditing access requests. This can help to prevent unauthorized access and ensure compliance with HIPAA regulations.

Choice C rationale:

Incorrect. Patients have a right to access their records at any time, not just when they are being discharged.

Delays access to information. Patients may need to review their records to make informed decisions about their care, even if they are not being discharged.

Potential for records to be lost or misplaced. There is a risk that records could be lost or misplaced if they are not provided to the patient until discharge.

Choice D rationale:

Incorrect. Patients do not need to provide a reason for wanting to access their medical records.

Intrusive and unnecessary. Patients may feel uncomfortable or embarrassed about having to explain their reasons for wanting to access their records.

Potential for discrimination. Patients may be less likely to request access to their records if they feel that they will be judged or questioned about their reasons for doing so.

Correct Answer is ["50"]

Explanation

Here are the steps to calculate the gtt/min for the manual IV infusion:

Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes

Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min

Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.

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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.Which of the following findings should the nurse identify as an indication that the client is dehydrated?

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a patient who requests to review his medical record. How should the nurse respond?

Correct Answer is B

Explanation

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hours. The drop factor of the manual IV tubing is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? (Input your answer into the blank space, without any units. Numerical value only.)

Correct Answer is ["50"]

Explanation

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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.
Which of the following findings should the nurse identify as an indication that the client is dehydrated?