A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Distended neck veins
Postural hypotension
Dependent edema
Bradycardia
The Correct Answer is B
A. Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B. In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C. Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D. Bradycardia is not typically associated with extracellular fluid volume deficit.
Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
Correct Answer is ["B","C","D"]
Explanation
A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.
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