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?
Elastic skin turgor
Dry mucous membranes
Oliguria
Tachycardia
The Correct Answer is A
Choice A reason: Elastic skin turgor is a sign of adequate hydration and fluid balance. Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled. When the skin is dehydrated, it loses its elasticity and becomes tented or wrinkled. The nurse should assess the skin turgor on the chest, abdomen, or forehead, and not on the hands or feet, which can be affected by aging or edema.
Choice B reason: Dry mucous membranes are a sign of fluid volume deficit, not fluid volume excess. Mucous membranes are the moist linings of the mouth, nose, eyes, and other body openings. When the body is dehydrated, the mucous membranes become dry, cracked, or sticky. The nurse should assess the mucous membranes for color, moisture, and capillary refill.
Choice C reason: Oliguria is a sign of fluid volume deficit, not fluid volume excess. Oliguria is the production of abnormally small amounts of urine, usually less than 400 mL per day or 30 mL per hour. Oliguria can indicate reduced kidney function, impaired blood flow to the kidneys, or inadequate fluid intake. The nurse should monitor the urine output, color, specific gravity, and presence of blood or protein.
Choice D reason: Tachycardia is a sign of fluid volume deficit, not fluid volume excess. Tachycardia is a rapid heart rate, usually more than 100 beats per minute. Tachycardia can occur when the body is dehydrated, as the heart tries to pump more blood to maintain the blood pressure and perfusion. The nurse should measure the pulse rate, rhythm, quality, and amplitude.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Drinking orange juice with iron supplements can increase absorption, not decrease it. Orange juice is rich in vitamin C, which enhances the absorption of non-heme iron, the type of iron found in plant foods and supplements. The nurse should advise the client to take iron supplements with a source of vitamin C, such as orange juice, strawberries, or tomatoes.
Choice B reason: Cooking in a stainless steel skillet does not increase the amount of iron in the food. Stainless steel is not a good conductor of iron and does not leach iron into the food. The nurse should suggest the client to use a cast iron skillet instead, which can add iron to the food, especially acidic foods like tomatoes or citrus fruits.
Choice C reason: Drinking iced tea with meals can decrease the amount of iron absorbed, not increase it. Iced tea contains tannins, which are compounds that bind to iron and inhibit its absorption. The nurse should recommend the client to avoid drinking tea, coffee, or other beverages that contain tannins with meals, and to drink them between meals instead.
Choice D reason: Fish and poultry are primary sources of heme iron, which is the type of iron found in animal foods and is more easily absorbed by the body. The nurse should encourage the client to eat more foods that are high in heme iron, such as fish, poultry, meat, and eggs.
Correct Answer is B
Explanation
Choice A reason: Ground beef is high in saturated fat and cholesterol, which can increase the risk of gallstones. A client with cholecystitis should avoid fatty, greasy, or fried foods; meats; and cheeses.
Choice B reason: Graham crackers are low in fat and high in fiber, which can help prevent gallstones. A client with cholecystitis should eat more foods that are high in fiber, such as fruits, vegetables, beans, and whole grains.
Choice C reason: Blueberry muffins may contain butter, eggs, or milk, which are sources of saturated fat and cholesterol. A client with cholecystitis should eat fewer refined carbohydrates and less sugar.
Choice D reason: 2% milk is a dairy product that contains saturated fat and cholesterol. A client with cholecystitis should eat healthy fats, like fish oil and olive oil, to help the gallbladder contract and empty on a regular basis.
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