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 B

Explanation

The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.

A. A client who received a Mantoux test 48 hr ago and has an induration. B. A client who is scheduled for a colonoscopy and is taking sodium phosphate. C. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L. D. A client who is taking warfarin and has an INR of 1.8.

Correct Answer is D

Explanation

The correct answer is choiced. A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.

Choice B rationale:

Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.

Choice D rationale:

An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.

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

Nursing Test Bank

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A nurse is assessing a client who is experiencing hypovolemia.

Which of the following manifestations should the nurse expect