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: Warming the formula to room temperature can help reduce the osmotic load and prevent diarrhea in clients receiving enteral nutrition. Cold formula can also cause abdominal cramping and discomfort.
Choice B reason: Increasing the rate of infusion can worsen diarrhea by increasing the osmotic load and the risk of bacterial overgrowth. The rate of infusion should be adjusted based on the client's tolerance and nutritional needs.
Choice C reason: Changing to a low-calorie formula is not indicated for diarrhea. Low-calorie formulas are usually high in osmolality and can cause more water to be drawn into the intestinal lumen, leading to diarrhea. A low-residue or isotonic formula may be more appropriate.
Choice D reason: Replacing the extension tubing every 48 hr is not enough to prevent diarrhea. The extension tubing should be replaced every 24 hr or with each new container of formula to reduce the risk of bacterial contamination and infection.
Correct Answer is B
Explanation
Choice B reason: Providing low-fat carbohydrates with meals can help reduce nausea and vomiting in clients who have equilibrium imbalance. Low-fat carbohydrates are easy to digest and can provide energy and prevent hypoglycemia. Examples of low-fat carbohydrates are crackers, toast, rice, and noodles.
Choice A reason: Serving hot foods at mealtime is not a good strategy for clients who have nausea from equilibrium imbalance. Hot foods can have strong odors and flavors that can trigger nausea and vomiting. Cold or room-temperature foods are more tolerable and less stimulating for the senses.
Choice C reason: Encouraging the client to eat even if nauseated is not a helpful strategy for clients who have nausea from equilibrium imbalance. Forcing the client to eat can worsen nausea and vomiting and cause discomfort and distress. The nurse should respect the client's preferences and appetite and offer small, frequent meals and snacks.
Choice D reason: Limiting fluid intake between meals is not a necessary strategy for clients who have nausea from equilibrium imbalance. Fluid intake is important to prevent dehydration and electrolyte imbalance, which can occur due to vomiting. The nurse should encourage the client to drink fluids between meals, but avoid drinking fluids with meals, as this can cause bloating and fullness.
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