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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice C reason: Flushing the tubing with water after each feeding is important to prevent clogging, maintain patency, and clear any residual formula from the tube. It also helps to prevent bacterial growth and infection.
Choice A reason: Wearing sterile gloves during a feeding is not necessary, as enteral feedings are not considered sterile procedures. Clean gloves are sufficient to prevent contamination and protect the nurse and the client.
Choice B reason: Chilling the feeding prior to administering is not recommended, as cold formula can cause abdominal cramping, discomfort, and diarrhea. The formula should be at room temperature or slightly warmed before giving it to the client.
Choice D reason: Positioning the client upright prior to a feeding is correct, but it is not enough. The client should remain upright for at least 30 minutes after the feeding as well, to prevent aspiration, reflux, and nausea.
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