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. Confidentiality: Confidentiality refers to the duty to respect and protect the client's private information and not disclose it without the client's consent or appropriate legal authorization.

B. Nonmaleficence: Nonmaleficence means "do no harm." It is the ethical principle that requires healthcare professionals to avoid causing harm to their clients and to balance potential benefits with possible risks.

C. Accountability: Accountability is the ethical principle that refers to the responsibility of healthcare professionals to answer for their actions and decisions in providing care to clients.

D. Autonomy: Correct. Autonomy is the ethical principle that respects a person's right to make their own decisions and about their healthcare. Allowing a client to make decisions about their treatment plan is an example of promoting autonomy and respecting their right to
selfdetermination.

A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

Correct Answer is D

Explanation

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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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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