how should a nurse assess a patient for dehydration

ATI RN

ATI RN Exit Exam Quizlet

1. How should a healthcare professional assess a patient for dehydration?

A. Check for skin turgor
B. Monitor blood pressure
C. Check for dry mucous membranes
D. Monitor urine output

Correct answer: A

Rationale: Checking for skin turgor is a reliable method to assess dehydration in patients. Skin turgor refers to the skin's elasticity and hydration status. When a healthcare professional gently pinches the skin on the back of the patient's hand or forearm, dehydration is indicated by the skin not snapping back immediately. Monitoring blood pressure (choice B) is important but is more indicative of cardiovascular status rather than dehydration specifically. Checking for dry mucous membranes (choice C) can be a sign of dehydration, but skin turgor is a more direct assessment. Monitoring urine output (choice D) is also essential but may not provide immediate feedback on hydration status as skin turgor does.

2. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?

A. Heart rate of 88/min
B. Serosanguineous drainage on the surgical dressing
C. Blood pressure of 118/76 mm Hg
D. Urine output of 40 mL/hr

Correct answer: D

Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.

3. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

A. Potassium 4.0 mEq/L
B. Hemoglobin 12 g/dL
C. BUN 18 mg/dL
D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

4. A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?

A. I will increase my intake of canned vegetables.
B. I will limit my daily sodium intake to 2 grams.
C. I will increase my intake of whole grains.
D. I will reduce my intake of processed meats.

Correct answer: D

Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.

5. When should healthcare professionals perform hand hygiene?

A. Before and after patient contact
B. Before and after performing procedures
C. After using the restroom
D. After touching contaminated surfaces

Correct answer: A

Rationale: Healthcare professionals should perform hand hygiene before and after patient contact to prevent the spread of infections. While choices B, C, and D are also important times to practice hand hygiene, they are not as crucial as before and after patient contact because patient contact poses a higher risk of transmitting infections.