A nurse in a critical care unit is assessing an adult client. Which of the following findings by the nurse indicates a fluid volume deficit?
Heart rate 118/min
Central venous pressure 25 mm Hg
Blood pressure 152/90 mm Hg
Temperature 37.2° C (99° F)
The Correct Answer is A
A. A heart rate of 118/min suggests tachycardia, which is a compensatory mechanism in response to fluid volume deficit. The body increases heart rate to maintain cardiac output when fluid volume is low.
B. A central venous pressure of 25 mm Hg may indicate fluid volume overload rather than deficit. It suggests increased venous pressure, possibly due to excess fluid.
C. A blood pressure of 152/90 mm Hg is within the normal range and does not specifically indicate fluid volume deficit.
D. A temperature of 37.2°C (99°F) is within the normal range and does not specifically indicate fluid volume deficit.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Legumes are a good source of protein but are considered an incomplete protein because they do not contain all essential amino acids.
B. Poultry is a complete protein as it contains all essential amino acids necessary for the human body.
C. Eggs are also a complete protein, providing all essential amino acids.
D. Nuts, similar to legumes, are an incomplete protein because they lack one or more of the essential amino acids.
E. Grains are typically incomplete proteins as they do not have all the essential amino acids that the body requires. However, when combined with other incomplete proteins, they can provide a complete protein profile.
Correct Answer is A
Explanation
A. Flushing the tubing with water at regular intervals helps prevent the buildup of formula residue and maintains tube patency. This is especially important with high-viscosity formulas, which are more prone to clogging small-bore tubes.
B. Administering the feeding by gravity drip is a method of delivery and does not directly address the prevention of tubing clogging.
C. While replacing the bag and tubing every 24 hours is a standard practice to reduce the risk of bacterial contamination, it does not specifically prevent tubing clogging.
D. Heating the formula prior to infusion may improve its flow characteristics but does not address the prevention of tubing clogging. Heating formula should be done according to manufacturer guidelines to avoid denaturation of nutrients.
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