A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

Full bounding pulse

Cool extremities

Moist crackles in the lungs

Orthostatic hypotension

Flat neck veins

Answer and Explanation

Correct Answer : B,D,E

A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit.
B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit.
C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit.
D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume.
E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.

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Correct Answer is D

Explanation

A. Provide an artificial voice box - This is not typically used for clients with aphasia as it does not address the communication barriers they face.
B. Avoid using facial gestures - Facial gestures can be a helpful non-verbal communication tool, especially for clients with aphasia, so avoiding them is not beneficial.
C. Speak to the client in a louder voice - Aphasia affects language processing, not hearing, so increasing volume does not aid in understanding.
D. Ask the client close-ended questions - This allows the client to respond with 'yes' or 'no', or other simple answers, which can be easier for someone with aphasia.

A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

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A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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