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 D
Explanation
A. Chicken, yams, pinto beans, and pecans: This meal is not ideal for a client with CKD because pinto beans and pecans are high in potassium and phosphorus, which can be problematic for clients with CKD. Yams are also high in potassium.
B. Steak and baked potato with butter and cheese topping: Steak is high in protein and phosphorus, which can overload the kidneys. Baked potato, especially with cheese, can be high in potassium, which should be monitored in CKD.
C. Canned ham and green beans: Canned ham is often high in sodium, which is not recommended for clients with CKD, as it can exacerbate fluid retention and high blood pressure. Green beans are a good choice, but the sodium content in the ham is a concern.
D. Pasta with fish and an orange: Pasta is low in potassium and phosphorus, and fish provides a good source of protein that is generally easier on the kidneys compared to red meat. This meal is lower in sodium, phosphorus, and potassium, making it a better choice for CKD.
Correct Answer is C
Explanation
A. Report any increase in the white blood cell count: While monitoring for signs of infection is important, an increase in WBC count alone does not address the risk of MRSA recurrence in the wound. Early intervention with infection control measures is more important.
B. Change the surgical dressing readily when soiled: Changing the dressing when soiled is necessary for wound hygiene but does not target MRSA recurrence. Adhering to infection control measures, like contact precautions, is more effective in preventing MRSA.
C. Instruct the family to adhere to contact precautions: Educating the family on contact precautions is critical for preventing the spread and recurrence of MRSA, especially in the postoperative period. It reduces the risk of contamination and protects both the patient and healthcare workers.
D. Wear a face mask while performing wound care: Wearing a face mask is not necessary for preventing MRSA transmission in the wound care setting. Contact precautions, including proper hand hygiene and wearing gloves, are more effective for MRSA prevention.
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