A nurse is assessing a client who is experiencing hypovolemia.

Which of the following manifestations should the nurse expect

Epistaxis

Headache

Dizziness

Shortness of breath

Answer and Explanation

The Correct Answer is C

, dizziness.

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.

Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.

Normal ranges for heart rate are 60 to 100 beats per minute for adults.

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Correct Answer is A

Explanation

The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.

Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.

Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.

Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.

Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.

Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.

A. Cross the client’s arms across their chest. B. Place the client in a high-Fowler’s position C. Hold the client’s eyes shut for a few seconds. D. Remove the client’s dentures from their mouth

Correct Answer is C

Explanation

The correct answer is choice C. Holding the client’s eyes shut for a few seconds.

This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.

This also gives a more peaceful appearance to the client’s body for the family visit.

Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.

Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.

Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.

Normal ranges are not applicable for this question as it does not involve any physiological measurements.

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A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

Correct Answer is A

Explanation

A nurse is performing postmortem care for a recently deceased client prior to the client’s family visit. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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A nurse is assessing a client who is experiencing hypovolemia.

Which of the following manifestations should the nurse expect