The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on Initial testing?
Reference Range: Urine Specific Gravity [1.005 to 1.03]
1.035.
1.015.
1.005.
1.025.
1.025.
The Correct Answer is A
A. 1.035:
This specific gravity value indicates highly concentrated urine. In the context of a client experiencing vomiting, diarrhea, and difficulty tolerating oral fluids, such a high specific gravity would be indicative of significant dehydration. Dehydration occurs when the body loses more fluid than it takes in, leading to an imbalance in electrolytes and an increase in urine concentration.
B. 1.015:
This specific gravity value falls within the normal reference range for urine specific gravity. In the context of vomiting, diarrhea, and difficulty tolerating oral fluids, a value within the normal range may be less likely. However, it's important to note that initial testing may not reflect the full extent of dehydration, especially if the client's fluid intake has been severely limited over a short period.
C. 1.005:
This specific gravity value is at the lower end of the normal reference range for urine specific gravity. In a client experiencing significant fluid loss through vomiting and diarrhea, the urine may become more concentrated as the body attempts to conserve water. Therefore, a value of 1.005 would be less likely on initial testing in this context.
D. 1.025:
Similar to Option B, this specific gravity value falls within the normal reference range. While it's possible for a dehydrated individual to have a specific gravity within the normal range, a value of 1.025 may be less likely in the context of significant fluid loss through vomiting and diarrhea. However, it's important to consider that dehydration severity and urine concentration can vary among individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Enter the occurrence after the 1400 notes and identify as "late entry":
While entering the occurrence after the 1400 notes is an option, labeling it as a "late entry" may not provide sufficient clarity regarding the timing of the documentation. Using a "late entry" label could potentially lead to confusion or misinterpretation.
B. Request removal initiated by the Health Information Manager:
Requesting removal of the 1400 notes by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.
C. Create an electronic correction after 1400 notes are officially unlocked:
Making an electronic correction implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
D. Make an electronic addendum following the 1400 documentation:
An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It's important to ensure that the addendum clearly identifies the timing of the documentation to maintain accuracy and transparency in the medical record.
Correct Answer is C
Explanation
A. Suctions secretions from the posterior pharynx:
Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.
B. Tests for a gag reflex before performing oral care:
Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.
C. Places the client in a supine position:
Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.
D. Uses an oral airway to keep the teeth apart:
Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.
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