A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
BUN 18 mg/dL.
A thready pulse.
Hemoglobin 15 g/dL.
Prominent neck veins.
The Correct Answer is B
The correct answer is choice B: A thready pulse.
Choice A rationale:
BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.
Choice B rationale:
A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.
Choice C rationale:
Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.
Choice D rationale:
Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Correct Answer is B
Explanation
The correct answer is choice B: Ask the client what they already know about meal planning.
Choice A rationale:
Using pictures of different food groups can be helpful in teaching about carbohydrate counting, but it's important to assess the client's current knowledge and understanding before introducing new information. Starting with this approach might overwhelm the client or duplicate information they already possess.
Choice B rationale:
This is the correct choice. Before providing education, it's crucial to assess the client's baseline knowledge. By asking the client what they already know about meal planning, the nurse can tailor the teaching plan to fill in any gaps and avoid presenting redundant information. This approach respects the client's current understanding and focuses on addressing their specific needs.
Choice C rationale:
Giving the client a brochure with sample menus can be helpful once the nurse has assessed the client's knowledge and educational needs. However, providing the brochure as the first action might not be effective if the client already has some understanding of meal planning or if the brochure does not address the client's specific questions.
Choice D rationale:
Involving the family in the discussion of the client's meal plan is important for long-term support, but it shouldn't be the first action. First, the nurse should ensure that the client's own understanding and preferences are addressed before considering input from family members.
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