A nurse is assessing a client who has dehydration.
Which of the following findings should the nurse expect?
Cloudy urine.
Urine osmolality of 200 mOsm/kg.
Urine specific gravity of 1.015.
Dark-colored urine.
The Correct Answer is D
Choice D rationale
Dark-colored urine is a common indicator of dehydration. When the body is dehydrated, urine becomes more concentrated, leading to darker color due to higher levels of waste products.
Choice A rationale
Cloudy urine is not typically associated with dehydration. It may indicate the presence of an infection, inflammation, or other medical conditions.
Choice B rationale
Urine osmolality of 200 mOsm/kg suggests diluted urine, which is contrary to the expectation in dehydration. Dehydration would typically result in higher urine osmolality as the kidneys conserve water.
Choice C rationale
Urine specific gravity of 1.015 falls within the normal range (1.005 to 1.030). In dehydration, specific gravity would be expected to be higher as the urine becomes more concentrated to conserve water.
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Correct Answer is B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is D
Explanation
Choice A rationale
It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.
Choice B rationale
Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.
Choice C rationale
Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.
Choice D rationale
Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.