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: Diabetes mellitus is not a likely complication of malnutrition, as it is caused by insufficient insulin production or action, not by inadequate food intake. Malnutrition may worsen the outcomes of diabetes, but it does not cause it.
Choice B reason: Pressure injury is a common complication of malnutrition, as it is caused by impaired tissue perfusion and oxygenation due to poor nutrition. Malnutrition can lead to loss of muscle mass, subcutaneous fat, and skin integrity, which increase the risk of developing pressure ulcers.
Choice C reason: Heat intolerance is not a direct complication of malnutrition, as it is caused by impaired thermoregulation due to hormonal or neurological disorders, not by insufficient food intake. Malnutrition may affect the body's ability to cope with heat stress, but it does not cause it.
Choice D reason: Gastroesophageal reflux disease (GERD) is not a typical complication of malnutrition, as it is caused by the backflow of gastric contents into the esophagus due to a weak or incompetent lower esophageal sphincter, not by inadequate food intake. Malnutrition may aggravate the symptoms of GERD, but it does not cause it.
Correct Answer is B
Explanation
The correct answer is: b. Offer the client frozen bananas as a snack.
Choice A: Discourage the use of a straw
Discouraging the use of a straw is not the best intervention for a client with stomatitis following radiation therapy. While using a straw might cause some discomfort, it is not a primary concern. The focus should be on providing soothing and non-irritating foods.
Choice B: Offer the client frozen bananas as a snack
Offering the client frozen bananas as a snack is an appropriate intervention. Frozen bananas can provide a soothing effect on the inflamed oral tissues and are less likely to cause irritation compared to other foods. They are also nutritious and easy to consume, making them a suitable option for clients with stomatitis.
Choice C: Serve the client hot meals
Serving hot meals is not recommended for clients with stomatitis. Hot foods can exacerbate the discomfort and irritation in the mouth, making it more painful for the client to eat. It is better to serve foods at a moderate or cool temperature to avoid further irritation.
Choice D: Avoid serving sauces or gravies
Avoiding sauces or gravies is not the best intervention for a client with stomatitis. While some sauces or gravies might be irritating, others can be soothing and help make the food easier to swallow. The key is to choose mild and non-spicy options that do not irritate the oral tissues.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.