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 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 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 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 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 C

Explanation

This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances. This could result in harm or death to the patient.

Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.

A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.

Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.

A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.

It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.

Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice.

A. Administer a fluid bolus. B. Initiate continuous bladder irrigation. C. Obtain a urine specimen for culture and sensitivity. D. Clamp the catheter tubing for 30 min.

Correct Answer is A

Explanation

The client has signs of dehydration and oliguria, which are low urine output and dark yellow urine. A fluid bolus can help restore the fluid balance and improve the renal perfusion. The normal urine output for an adult is 0.5-1.5 mL/kg/hr, and the client’s urine output is only 25 mL/hr, which is below the minimum acceptable level. Dark yellow urine can indicate a high concentration of waste products and a low intake of fluids.

Choice B is wrong because continuous bladder irrigation is used to prevent or treat blood clots in the bladder after surgery or injury, not to increase urine output.

Choice C is wrong because a urine specimen for culture and sensitivity is used to diagnose a urinary tract infection, which is not the most likely cause of the client’s low urine output.

The client does not have other symptoms of infection, such as fever, pain, or cloudy urine.

Choice D is wrong because clamping the catheter tubing for 30 min can cause urinary retention, bladder distension, and increased risk of infection.

It can also interfere with the accurate measurement of urine output.

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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

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Explanation

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Correct Answer is A

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