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?

Temperature 37.2°C (99°F).

Pulse rate 118/min.

Blood pressure 152/90 mm Hg.

Central venous pressure 25 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
A temperature of 37.2°C (99°F) is within the normal range (approximately 36.5°C to 37.5°C or 97.7°F to 99.5°F) and does not specifically indicate fluid volume deficit. It's important to consider this value along with other findings.
Choice B rationale:
(Correct Choice) A pulse rate of 118/min is indicative of tachycardia, which can be a sign of fluid volume deficit. When the body is experiencing a decrease in fluid volume, the heart rate often increases as a compensatory mechanism to maintain adequate circulation. Tachycardia helps to pump a reduced blood volume more rapidly to vital organs.
Choice C rationale:
A blood pressure of 152/90 mm Hg is elevated but does not solely indicate a fluid volume deficit. While low blood pressure can be a sign of dehydration, high blood pressure does not necessarily correlate directly with fluid volume status.
Choice D rationale:
Central venous pressure (CVP) of 25 mm Hg is elevated. CVP reflects the pressure in the vena cava and right atrium, indicating the amount of blood returning to the heart. An elevated CVP might be seen in fluid volume excess or right-sided heart failure, not fluid volume deficit.

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Correct Answer is D

Explanation

Choice A rationale: 1 cup of milk contains about 100 mg of sodium. This is a moderate amount of sodium, but it is not the highest compared to the other options.

Choice B rationale: 4 oz of vanilla pudding contains about 153 mg of sodium. This is higher than the sodium content in 1 cup of milk, but we need to compare it with the other options.

Choice C rationale: 1/2 cup of yogurt contains about 86 mg of sodium. This is less than the sodium content in both 1 cup of milk and 4 oz of vanilla pudding.

Choice D rationale: 2 oz of processed cheese can contain around 375 mg of sodium. This is significantly higher than the sodium content in 1 cup of milk, 4 oz of vanilla pudding, and 1/2 cup of yogurt.

So, the correct answer is, after analyzing all choices, D. 2 oz of processed cheese has the highest sodium content.

A. Initiate a calorie count of daily food intake. B. Provide food in a thin liquid consistency. C. Instruct the client to keep their chin up when swallowing. D. Place the client in a semi-Fowler's position when eating.

Correct Answer is D

Explanation

Choice A rationale:
Initiating a calorie count of daily food intake is not directly related to addressing dysphagia. Calorie counts might be important in certain situations, such as managing weight, but it does not directly address the client's swallowing difficulties.
Choice B rationale:
Providing food in a thin liquid consistency is contraindicated for a client with dysphagia. Thin liquids can increase the risk of aspiration in individuals with swallowing difficulties. The nurse should choose thicker liquids and modify the diet as recommended by a speech-language pathologist or healthcare provider.
Choice C rationale:
Instructing the client to keep their chin up when swallowing is not an appropriate action for addressing dysphagia. Instead, clients with dysphagia are often instructed to tuck their chin down to their chest when swallowing. This helps to close off the airway and prevents food or liquids from entering the airway.
Choice D rationale:
Placing the client in a semi-Fowler's position when eating is the correct action. This position helps prevent aspiration by promoting proper alignment of the airway and esophagus. The semi-Fowler's position involves elevating the head of the bed to an angle of 30-45 degrees. This position facilitates swallowing and reduces the risk of choking or aspiration.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

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