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
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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Related Questions
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.
Correct Answer is C
Explanation
A. Potassium chloride: Potassium chloride is used to treat hypokalemia, not hyperkalemia.
B. Acetylcysteine: This medication is not used to treat potassium imbalances. It is primarily used to treat acetaminophen overdose or to thin mucus in respiratory conditions.
C. Sodium polystyrene: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, helping to lower serum potassium levels.
D. Potassium iodide: Potassium iodide is used in thyroid conditions (such as thyroid storm) or radiation exposure and is not used to manage potassium levels.
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