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A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)

A nurse is assessing a client who reports taking a medication that causes increased urination resulting in dehydration for the past 3 days. Which findings should the nurse expect in a client who is dehydrated? (Select all that apply.)

 A nurse in an emergency department (ED) is admitting a client.

Vital Signs 

1000:

Temperature 38.6° C (101.5° F)

Heart rate 106/min

Respiratory rate 26/min

Blood pressure 110/54 mm Hg

Oxygen saturation 94% on room air

Nurses Notes 

1000:

Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.

Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.

Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.

Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

Which lung sounds are expected? (Select all that apply.)

A nurse is caring for a client who has a body mass index (BMI) of 26. The nurse should place the client in which BMI category?

The nurse reviews the arterial blood gas results of an assigned client and notes the laboratory report results

pH of 7.30, [normal pH is 7.35 to 7.45]

Paco2 of 58 mm Hg, [Normal Paco2 is 35 to 45 mm Hg]

Pao2 of 80 mm Hg. [normal is 80-100]

HCO3 of 27 mEq/L (27 mmol/L). [Normal HCO3 is 22-26]

The nurse interprets that the client has which acid-base disturbance?

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods that should be avoided. Which food should the nurse encourage the client to avoid?

To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?