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
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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Keeping the crutch tips dry is essential to prevent slipping and falling, which can lead to further injury. Moisture on the tips can reduce friction, making the crutches unstable on surfaces.
B.When sitting down, the correct technique involves holding both crutches in one hand and using the other hand to lower yourself safely into the chair. Holding a crutch in each hand can make it difficult to balance and sit down safely.
C.Placing weight on the underarms can cause nerve damage and pain. The correct technique is to place weight on the hands and use the muscles of the arms and shoulders to support the body.
D. When going upstairs with a fractured leg, the proper technique is to lead with the uninjured leg, not the injured one. This ensures stability and reduces the risk of further injury to the fractured leg.
Correct Answer is B
Explanation
A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
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