The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

Urine specific gravity

Serum hematocrit

Pulse rate

Urinary output

Answer and Explanation

The Correct Answer is D

Choice A reason: Urine specific gravity is a measure of the concentration of solutes in the urine. It is inversely related to the hydration status of the client. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration.

Choice B reason: Serum hematocrit is a measure of the percentage of red blood cells in the blood. It is also inversely related to the hydration status of the client. A high serum hematocrit indicates dehydration, while a low serum hematocrit indicates overhydration.

Choice C reason: Pulse rate is a measure of the frequency of the heartbeats. It is directly related to the hydration status of the client. A low pulse rate indicates dehydration, while a high pulse rate indicates overhydration.

Choice D reason: Urinary output is a measure of the amount of urine produced by the kidneys. It is directly related to the hydration status of the client. A low urinary output indicates dehydration, while a high urinary output indicates overhydration.

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Correct Answer is B

Explanation

Choice A reason:This directive approach may pressure the client to discuss details they are not ready to share, potentially causing discomfort.

Choice B reason:This open-ended offer demonstrates the nurse's availability and support, allowing the client to decide whether to engage in conversation, thereby respecting their autonomy.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

A. Review the chart for number of voids over the last 24 hours. B. Palpate the suprapubic region for distention. C. Evaluate the client for urinary incontinence. D. Scan the client's bladder after voiding.

Correct Answer is D

Explanation

Choice A reason: Reviewing the chart for number of voids over the last 24 hours is not the best action to evaluate the client for urinary retention. It may provide some information about the client's urinary pattern, but it does not indicate the amount of urine left in the bladder after voiding.

Choice B reason: Palpating the suprapubic region for distention is a useful action to assess the client for urinary retention, but it is not the most accurate or reliable method. It may be difficult to palpate the bladder if the client is obese, has abdominal pain, or has bowel distention.

Choice C reason: Evaluating the client for urinary incontinence is not relevant to the assessment of urinary retention. Urinary incontinence is the involuntary loss of urine, while urinary retention is the inability to empty the bladder completely.

Choice D reason: Scanning the client's bladder after voiding is the best action to evaluate the client for urinary retention. It is a noninvasive and precise technique that measures the post-void residual urine volume. A normal post-void residual is less than 50 mL, while a high post-void residual indicates urinary retention.

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The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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