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 D
Explanation
The correct answer is choice d. The client’s output was 60 mL for the past 3 hr.
Choice A rationale:
Voiding three times during the night (nocturia) is common in chronic kidney disease (CKD) due to the kidneys’ inability to concentrate urine. While it should be monitored, it is not the most urgent issue.
Choice B rationale:
Burning and discomfort with urination could indicate a urinary tract infection (UTI), which is important to address but not as immediately critical as low urine output.
Choice C rationale:
A WBC count of 11,000/mm² is slightly elevated and could indicate an infection or inflammation, but it is not as urgent as the low urine output.
Choice D rationale:
Low urine output (oliguria) of 60 mL over 3 hours is a critical finding in CKD patients. It indicates potential acute kidney injury or worsening kidney function, which requires immediate attention to prevent further complications.
Correct Answer is C
Explanation
The correct answer is choice C. Pallor with scaly skin.
Choice A rationale:
"Heart rate 89/min." Heart rate within the range of 60-100 beats per minute is generally considered normal for adults at rest. This value doesn't specifically indicate malnourishment.
Choice B rationale:
"Pink mucous membranes." Pink mucous membranes indicate adequate oxygenation and hydration but don't necessarily reflect nutritional status or malnourishment.
Choice C rationale:
"Pallor with scaly skin." Pallor (pale skin) along with scaly skin can be indicative of malnourishment. Malnourished individuals may not receive adequate n
Choice D rationale:
"Body mass index 23." A body mass index (BMI) of 23 falls within the normal range (18.5-24.9), so it doesn't necessarily indicate malnourishment. However, BMI alone may not fully capture malnourishment, as it doesn't consider other factors like muscle mass and specific nutrient deficiencies.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today