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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A well approximated incision site:

A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.

B. Erythema and serosanguineous exudate:

Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.

C. Eschar and slough in the wound:

Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.

D. Beefy red granulation tissue:

Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.

A. Initiate the facility's restraint flow sheet. B. Ensure that the restraints are not too tight. C. Demonstrate proper securing of the restraints. D. Complete an adverse occurrence/incident report.

Correct Answer is C

Explanation

A. Initiate the facility's restraint flow sheet:

- Initiating the facility's restraint flow sheet is an important step for documenting the use of restraints according to institutional policies and regulatory requirements. However, in this scenario where improper use of restraints has been observed, the immediate priority is to address the safety concern and prevent harm to the client.

B. Ensure that the restraints are not too tight:

- Ensuring that the restraints are not too tight is crucial for preventing harm to the client, such as compromised circulation or tissue damage. However, while important, this action is secondary to addressing the observed improper use of restraints, which poses an immediate safety risk to the client.

C. Demonstrate proper securing of the restraints:

Educating the UAP on how to correctly apply restraints is crucial. Incorrectly secured restraints can lead to complications such as injury, infection, or impaired circulation. The nurse should show the UAP how to secure the restraints to amovable part of the bed frame, not to the side rails. This ensures safety and prevents harm if the side rails are released.Proper restraint application helps maintain the client’s safety while minimizing risks.

D. Complete an adverse occurrence/incident report:

- Completing an adverse occurrence/incident report: Reporting incidents is necessary, but it can wait until after ensuring safe restraint application.

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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]

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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]