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

Answer and Explanation

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.

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Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

A. Vesicular sounds B. Wheezing sounds C. Crackles sounds D. Bronchovesicular sounds

Correct Answer is B

Explanation

When someone has asthma, their lungs may produce a wheezing sound when they breathe in and out. Narrowed airways and restricted air movement through the lungs may be responsible for the wheezing sound.

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KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

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Correct Answer is B

Explanation

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

Correct Answer is B

Explanation

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