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 B
Explanation
A. "I am sorry to disturb you at a difficult time. This can wait until later."
This response acknowledges the client's distress but does not actively engage with the client's emotions or offer support. It also suggests postponing the assessment, which may not be necessary if the client is willing to discuss their feelings.
B. “While touching the client's forearm, asks, 'Would you like to talk about it?'"
This response demonstrates empathy and offers the client an opportunity to express their feelings if they wish to do so. By gently touching the client's forearm and asking if they would like to talk, the nurse conveys support and openness to the client's emotional needs.
C. "This is a bad time. I can see you are upset. I can come back later."
While this response acknowledges the client's emotions and offers to return later, it may not be the most helpful approach. It assumes that the client does not want to engage in conversation at that moment without giving them the opportunity to express their preferences.
D. “Gives the client a hug and says, 'It is okay to cry when you are sad.'"
While offering physical comfort like a hug can be appropriate in some situations, it's important to respect the client's personal boundaries and preferences, especially if they are in distress. Additionally, some clients may not feel comfortable with physical touch from healthcare providers. This response also assumes the client's emotions without directly addressing their needs or offering them an opportunity to express themselves verbally.
Correct Answer is C
Explanation
A. Blood pressure is 142/88 mm Hg:
While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.
B. Radial pulse volume is 3+:
A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.
C. 2+ edema of fingers and hands:
Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.
D. Capillary refill time is 2 seconds:
Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.
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