A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

(Select All that Apply.)

Bradycardia

Pale Yellow Urine

Poor Skin Turgor

Hypotension

Flat Neck Veins

Answer and Explanation

Correct Answer : C,D,E

A. Bradycardia: Vomiting and diarrhea usually lead to tachycardia (increased heart rate) as the body compensates for hypovolemia, not bradycardia (slow heart rate).

B. Pale Yellow Urine: Dehydration often causes the urine to become concentrated and dark yellow, not pale yellow.

C. Poor Skin Turgor: Poor skin turgor is a classic sign of dehydration caused by fluid loss.

D. Hypotension: Loss of fluid volume can result in hypotension due to reduced blood circulation.

E. Flat Neck Veins: Dehydration causes reduced venous return, leading to flat neck veins, particularly when lying down.

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Correct Answer is B

Explanation

A. Hematoma: A hematoma typically results from bleeding into the tissue, causing swelling and bruising at the infusion site, but it doesn't usually cause warmth or pain in the same way as phlebitis.

B. Phlebitis: Phlebitis is inflammation of the vein, commonly caused by an IV catheter or medication, and it often presents with redness, warmth, pain, and swelling at the infusion site. It is the most likely complication here.

C. Speed Shock: Speed shock occurs when a medication or fluid is administered too rapidly, causing symptoms such as dizziness, chest tightness, and hypotension, not localized symptoms like redness and pain at the infusion site.

D. Thrombosis: Thrombosis refers to the formation of a blood clot within a vein, which can cause swelling, warmth, and discomfort but would also likely involve more significant blockage and would be associated with reduced blood flow, not just localized redness and pain.

A. Provide oxygen at 2 L per nasal cannula. B. Provide a urinal and encourage the patient to void. C. Place the patient in a high Fowler position. D. Lay the patient flat in bed to listen to bowel sounds.

Correct Answer is C

Explanation

A. Provide oxygen at 2 L per nasal cannula: Although oxygen might be helpful later, the patient currently has a good oxygen saturation (95%). The priority is to ease breathing and reduce fluid accumulation in the lungs.

B. Provide a urinal and encourage the patient to void: While voiding might help reduce fluid volume, repositioning the patient to improve breathing is more urgent.

C. Place the patient in a high Fowler position: This position maximizes lung expansion, improves oxygenation, and helps alleviate dyspnea caused by fluid overload.

D. Lay the patient flat in bed to listen to bowel sounds: Placing the patient flat can worsen pulmonary symptoms by allowing fluid to shift toward the lungs.

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A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

An 87-year-old patient recovering from abdominal surgery has a continuous intravenous infusion to supply nutrients and antibiotics. What complication should you suspect when signs and symptoms of redness, warmth, and pain at the infusion site are reported?

Correct Answer is B

Explanation

While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Correct Answer is C

Explanation

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