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?
Pulse rate 118/min
Blood pressure 152/90 mm Hg
Temperature 37.2° C (99° F)
Central venous pressure 25 mm Hg
The Correct Answer is A
A. Pulse rate of 118/min: In a client with fluid volume deficit, the pulse rate often increases as the body compensates for reduced blood volume.
B. Blood pressure of 152/90 mm Hg: This blood pressure reading does not specifically indicate fluid volume deficit as it can be influenced by various factors, including vascular tone and cardiac function.
C. Temperature of 37.2° C (99° F): This temperature reading is within the normal range and does not directly reflect fluid volume status.
D. Central venous pressure 25 mm Hg: This is elevated and typically suggests fluid volume excess rather than deficit.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulse rate of 118/min: In a client with fluid volume deficit, the pulse rate often increases as the body compensates for reduced blood volume.
B. Blood pressure of 152/90 mm Hg: This blood pressure reading does not specifically indicate fluid volume deficit as it can be influenced by various factors, including vascular tone and cardiac function.
C. Temperature of 37.2° C (99° F): This temperature reading is within the normal range and does not directly reflect fluid volume status.
D.Central venous pressure 25 mm Hg: This is elevated and typically suggests fluid volume excess rather than deficit.
Correct Answer is C
Explanation
"Position the newborn at a 20-degree angle after feeding": This is the correct instruction. After feeding, it is beneficial to position the newborn at a slight angle, usually around 20 degrees, to help reduce gastroesophageal reflux. This position helps gravity keep the stomach contents down and prevents them from regurgitating back into the esophagus.
"Provide a small feeding just before bedtime": This instruction is not recommended for a newborn with gastroesophageal reflux. It is advisable to avoid feeding the baby just before bedtime as lying down can worsen the reflux symptoms. Instead, it is generally recommended to keep the baby upright for some time after feeding to allow for proper digestion and minimize reflux.
"Place the newborn in a side-lying position if vomiting": Placing the newborn in a side-lying position after vomiting is not recommended. This position does not provide adequate support to prevent choking or aspiration in case of vomiting. Instead, it is recommended to keep the newborn in an upright or slightly elevated position after feeding to minimize reflux.
"Dilute formula with 1 tablespoon of water": Diluting formula with water is not a recommended practice unless specifically advised by a healthcare provider. It is important to follow the instructions on the formula packaging or the healthcare provider's guidance regarding formula preparation to ensure appropriate nutrition and hydration for the newborn.
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