A nurse is caring for a client who has fluid volume deficit and is receiving a continuous IV infusion. Which of the following findings indicates the treatment has been effective?
Oliguria
Elastic skin turgor
Tachycardia
Dry mucous membranes
The Correct Answer is B
A) Oliguria, or decreased urine output, is a sign of fluid volume deficit rather than an indication that the treatment has been effective. In a client with fluid volume deficit, the kidneys conserve water to maintain fluid balance, leading to decreased urine output.
B) Elastic skin turgor is a reliable indicator of hydration status. When a client's fluid volume deficit is improving, their skin turgor returns to normal. Elastic skin turgor means that the skin quickly returns to its normal position after being pinched and released, indicating adequate hydration.
C) Tachycardia, or an increased heart rate, is a compensatory mechanism that the body uses to maintain cardiac output in response to fluid volume deficit. While tachycardia may initially be present in a client with fluid volume deficit, it is not an indication that treatment has been effective.
D) Dry mucous membranes are a manifestation of dehydration and fluid volume deficit. Moist mucous membranes indicate hydration status, and their dryness suggests dehydration. Dry mucous membranes are not indicative of effective treatment for fluid volume deficit.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The client is immune to the rubella virus:
A negative rubella titer indicates that the client is not immune to the rubella virus. Therefore, this interpretation is incorrect.
B) The client requires a rubella vaccination at this time:
A negative rubella titer indicates susceptibility to rubella and the need for vaccination. However, administering a live virus vaccine like rubella during pregnancy is contraindicated due to the risk of fetal harm. Therefore, this interpretation is incorrect.
C) The client requires a rubella immunization following delivery:
A negative rubella titer during pregnancy indicates susceptibility to rubella. After delivery, the client should receive a rubella immunization to prevent rubella infection in future pregnancies. Rubella vaccination is safe postpartum and helps protect the mother and future pregnancies. Therefore, this interpretation is correct.
D) The client is not experiencing a rubella infection at this time:
A rubella titer measures the level of antibodies to the rubella virus, not the presence of an active infection. A negative rubella titer indicates the absence of immunity to rubella, not the absence of an active infection. Therefore, this interpretation is incorrect.
Correct Answer is A
Explanation
A) If the infant turns away after taking most of the feeding, it's a sign that they are full. Continuing to feed them after they ’ave indicated fullness can lead to overfeeding and discomfort. Therefore, it's important for the parents to recognize cues of satiety and sto’ the feeding accordingly.
B) Formula should not be changed to whole milk until the infant is at least 12 months old. Whole milk is not recommended as a replacement for formula before this age because it does not provide the appropriate balance of nutrients required for infant growth and development.
C) Formula that remains in the bottle should not be saved for another feeding because bacteria from the infant's mouth can contaminate the formula, increasing the risk of infe’tion. Any unused formula should be discarded after the feeding session.
D) Diluting formula to slow down weight gain is not recommended and can lead to inadequate nutrition for the infant. Infants should receive the appropriate concentration of formula to meet their nutritional needs for growth and development. If concerns arise about weight gain, parents should consult with their healthcare provider for appropriate guidance and recommendations.
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