A nurse is evaluating a client who is being treated for ...

[Redwolflake15]

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
 
  a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
  b. Decreased skin turgor on the client's posterior hand and forehead
  c. Increased urine specific gravity from 1.012 to 1.030 g/mL
  d. Decreased orthostatic light-headedness and dizziness

Question 2

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
 
  a. Client taking furosemide (Lasix)
  b. Anxious client who has tachypnea
  c. Client who is on fluid restrictions
  d. Client who is constipated with abdominal pain

[mcinincha279]

Answer to Question 1

ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

Answer to Question 2

ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.