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 C

Explanation

A. Obtaining clarification from a client's healthcare power-of-attorney:

While clear communication is important in this scenario, SBAR may not be necessary as the nurse is seeking information rather than providing a detailed report or recommendation.

B. Completing discharge teaching to a client and family members:

SBAR may not be the most suitable format for discharge teaching, as it is primarily used for communication between healthcare providers regarding a patient's condition and care plan. Discharge teaching typically involves providing comprehensive instructions and information in a manner tailored to the needs of the client and family members.

C. Reporting a change in a client's condition to the healthcare provider:

This is the most appropriate scenario for using the SBAR format. When communicating a change in a client's condition to the healthcare provider, the SBAR framework allows the nurse to provide a concise summary of the situation, relevant background information, assessment findings, and recommendations for further action.

D. Offering therapeutic support and comfort to a grieving family:

SBAR communication is not suitable for offering therapeutic support and comfort to a grieving family. This interaction requires empathy, active listening, and emotional support rather than a structured communication format like SBAR.

A. Capillary refill of 2 seconds in the lower right foot. B. Basilar lung sounds that are diminished in the left lung. C. Contraction of the left pupil when light shines in the right eye. D. Active bowel sounds in the lower right quadrant.

Correct Answer is B

Explanation

A. Capillary refill of 2 seconds in the lower right foot:

Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.

B. Basilar lung sounds that are diminished in the left lung:

Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.

C. Contraction of the left pupil when light shines in the right eye:

Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.

D. Active bowel sounds in the lower right quadrant:

Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.

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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]