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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Decreasing intake of omega-3 fatty acids would not be recommended for promoting cardiovascular health. Omega-3 fatty acids are essential fats that have been shown to have various heart-protective effects, such as reducing inflammation, lowering triglyceride levels, and improving overall cardiovascular health.
Choice B rationale:
Increasing the intake of whole grains is a sound recommendation for promoting cardiovascular health. Whole grains are rich in dietary fiber, vitamins, and minerals. They can help lower cholesterol levels, improve blood sugar control, and contribute to a healthy cardiovascular system.
Choice C rationale:
Decreasing the intake of potassium is not advisable for cardiovascular health. Potassium is a mineral that plays a crucial role in maintaining proper heart and muscle function. Adequate potassium intake can help regulate blood pressure and reduce the risk of stroke.
Choice D rationale:
Increasing the intake of refined carbohydrates is not a suitable recommendation for cardiovascular health. Refined carbohydrates, such as sugary snacks and white bread, can lead to spikes in blood sugar levels, weight gain, and an increased risk of heart disease.
Correct Answer is C
Explanation
Choice A rationale:
Salami. Salami is a processed meat product that is typically not recommended for individuals with celiac disease. It might contain additives, preservatives, and flavorings that could potentially contain gluten or cross-contamination. While the primary concern in celiac disease is gluten, it's also important to avoid processed meats due to potential hidden sources of gluten.
Choice B rationale:
Wheat germ. Wheat germ is derived from wheat and therefore contains gluten. For individuals with celiac disease, avoiding all sources of gluten is crucial to prevent immune reactions and damage to the intestines. Recommending wheat germ to a client with celiac disease would be contradictory to their dietary needs.
Choice C rationale:
Corn. Corn is a gluten-free grain and is a safe choice for individuals with celiac disease. It is a versatile food ingredient that can be used in various forms, such as cornmeal, cornstarch, and corn flour. Corn does not contain gluten and can be included in a gluten-free diet without any adverse effects.
Choice D rationale:
Barley. Barley is a gluten-containing grain and should be avoided by individuals with celiac disease. It contains gluten proteins that can trigger immune responses and cause damage to the small intestine. Including barley in the diet of a client with celiac disease would worsen their condition and lead to gastrointestinal symptoms.
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