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 B
Explanation
A. Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment.
B. Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger.
C. Lowpitched buzzer doorbell: A lowpitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety.
D. Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.
Correct Answer is A, B, C, D
Explanation
Sequence of Actions:
A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire.
B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system.
C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire's progress and safeguarding other parts of the building.
D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.
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