KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to find initially before fluid balance reaches homeostasis?
Crackles to Bilateral lobes
Tenting skin and wet mucous membranes
C Tachycardia and hypotension
+4 edema to bilateral lower extremities and confusion
The Correct Answer is C
Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with fluid overload, but not with dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.
Correct Answer is ["A","B","E"]
Explanation
These are all electrolyte imbalances. Hyperkalaemia is an elevated level of potassium in the blood. Hypocalcaemia is a low level of calcium in the blood. Hyponatremia is a low level of sodium in the blood. Thrombocytopenia and anemia are not electrolyte imbalances. Thrombocytopenia is a low platelet count and anemia is a low red blood cell count or low hemoglobin levels.
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