Exhibits
The nurse reviews the intake information prior to seeing the client.
What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.
Temperature 99.9° F (37.7° C)
Respirations 34 breaths/minute
Heart rate 136 beats/minute
Weak peripheral pulses
Dry mucous membranes
Body mass index (BMI) 21.9 kg/m2
Blood pressure 100/52 mm Hg
Poor skin turgor
Correct Answer : C,D,E,G,H
A. Temperature 99.9° F (37.7° C): A mild fever (99.9°F) is not a direct indicator of dehydration but could be related to other factors, including the body’s response to stress. It is not an immediate priority compared to other signs like poor skin turgor or low blood pressure.
B. Respirations 34 breaths/minute: An elevated respiratory rate may occur with dehydration, but it is not specific to dehydration alone. It should be monitored, especially when combined with other symptoms, but it is not a sole indicator of dehydration.
C. Heart rate 136 beats/minute: A heart rate of 136 beats per minute is elevated and may indicate dehydration, as the body attempts to compensate for reduced blood volume. Tachycardia is a common response to fluid loss and requires immediate follow-up.
D. Weak peripheral pulses: Weak peripheral pulses reflect poor circulation, which can be a result of dehydration. This finding indicates decreased perfusion and demands urgent attention to restore fluid balance and ensure proper circulation.
E. Dry mucous membranes: Dry mucous membranes are a hallmark sign of dehydration, as the body reduces fluid availability for non-essential processes. This finding should be immediately addressed, as it is a clear sign of fluid loss.
F. Body mass index (BMI) 21.9 kg/m²: BMI is a general indicator of body weight and is not related to fluid balance. While it provides useful information about the client’s overall health, it does not directly point to dehydration or fluid loss.
G. Blood pressure 100/52 mm Hg: Low blood pressure, especially in the context of dehydration, is a significant concern. A blood pressure of 100/52 mm Hg is a sign of hypovolemia or fluid loss, and immediate intervention is needed to restore normal fluid volume and prevent shock.
H. Poor skin turgor: Poor skin turgor is a classic sign of dehydration, where the skin remains tented after being pinched. This indicates a lack of sufficient fluid in the body, which must be addressed immediately to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clitoris: This is a highly sensitive erectile tissue and not connected to the urinary system.
B. Urethra: This is the correct site for catheter insertion, as it leads directly into the urinary bladder.
C. Labia: These are external folds of skin that surround the urethral and vaginal openings, not the site for catheter insertion.
D. Vagina: Inserting a catheter here would result in incorrect placement. The vagina is posterior to the urethra.
Correct Answer is A
Explanation
A. Yogurt or buttermilk: Cefdinir can disrupt the normal balance of bacteria in the gut. Yogurt or buttermilk, which contain probiotics, can help restore beneficial bacteria and reduce the risk of gastrointestinal complications such as antibiotic-associated diarrhea.
B. Avocados and cheese: While these are healthy foods, they do not specifically support gut health in the same way that probiotics do. Additionally, cheese may be high in fat and could potentially exacerbate gastrointestinal discomfort.
C. Fresh fruits: Fresh fruits provide important vitamins and fiber, but they do not specifically target the restoration of normal gut flora. Some fruits may also be difficult for a client with a postoperative wound infection to tolerate, especially if they are experiencing digestive issues.
D. Green leafy vegetables: While green leafy vegetables are nutritious, they do not have a direct role in supporting gut flora during antibiotic therapy. They are rich in vitamins and minerals, but the focus should be on probiotics like yogurt or buttermilk.
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