Among the following, which is not a clinical finding of a severely dehydrated patient?
Skin pallor and cool-to-touch skin
Pitting edema
Tachycardia with thready pulse
Lung sounds diminished with crackles upon auscultation
Urine Specific gravity of 1.035 D. Blood sodium 150 mEq/L
The Correct Answer is B
Choice A rationale
Skin pallor and cool-to-touch skin are common signs of severe dehydration. When the body is severely dehydrated, blood flow to the skin decreases, causing the skin to feel cool and look pale.
Choice B rationale
Pitting edema is not a clinical finding of severe dehydration. In fact, it’s quite the opposite. Pitting edema is a condition that causes swelling due to fluid accumulation, often due to conditions like heart failure, liver disease, or kidney disease.
Choice C rationale
Tachycardia with a thready pulse is a common sign of severe dehydration. The heart rate increases in an attempt to maintain blood flow to the organs, and the pulse may feel weak or thready due to low blood volume.
Choice D rationale
Lung sounds diminished with crackles upon auscultation is not typically associated with dehydration. This is more commonly seen in conditions affecting the lungs such as pneumonia or heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.
Choice B rationale
Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.
Choice C rationale
Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.
Choice D rationale
Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.
Correct Answer is B
Explanation
Choice A rationale
Unplugging the cord by holding the plug is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice B rationale
Ensuring the plug has three prongs is the most important action to prevent electrical hazards when administering intravenous fluids. A three-prong plug is grounded and reduces the risk of electrical shock.
Choice C rationale
Avoiding rolling equipment over extension cords is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
Choice D rationale
Plugging in the pump close to the socket is a good practice to prevent electrical hazards, but it is not the most important action when administering intravenous fluids.
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