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 A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Correct Answer is A
Explanation
Choice A reason: Vitamin D is a fat-soluble vitamin that is essential for bone health, immune function, and calcium absorption. It is mainly obtained from exposure to sunlight and animal sources, such as dairy products, eggs, and fish. Vegans are at risk for vitamin D deficiency, especially if they live in areas with limited sunlight or do not take supplements.
Choice B reason: Vitamin C is a water-soluble vitamin that is important for collagen synthesis, wound healing, and antioxidant activity. It is abundant in plant sources, such as fruits and vegetables. Vegans are not likely to be deficient in vitamin C, unless they have a very restricted diet or a malabsorption disorder.
Choice C reason: Magnesium is a mineral that is involved in many enzymatic reactions, muscle contraction, nerve transmission, and bone formation. It is widely distributed in plant and animal foods, such as nuts, seeds, legumes, grains, and green leafy vegetables. Vegans are not prone to magnesium deficiency, unless they have a chronic condition that affects magnesium absorption or excretion.
Choice D reason: Folic acid is a water-soluble vitamin that is essential for DNA synthesis, cell division, and red blood cell production. It is found in fortified grains, cereals, breads, and pasta, as well as in dark green leafy vegetables, beans, and lentils. Vegans are not at risk for folic acid deficiency, as long as they consume enough of these foods or take supplements.
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