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. Keep the conversation moving by asking about the client's family: While engaging the client in conversation is important, this statement does not specifically address the client's difficulty in talking about their illness.
B. Let the client know that as their nurse, they are available and willing to listen: Correct. This response demonstrates the nurse's willingness to provide emotional support and active listening. Encouraging the client to express their feelings and concerns about their illness is essential in promoting therapeutic communication.
C. Ask if the client understands what to expect in the advanced stages of the illness: While discussing the client's understanding of their illness is essential, it does not directly address their difficulty in talking to others about it.
D. Ask the client's visitors not to say anything about the advanced disease: This response may hinder communication and restrict the client's opportunity to talk about their feelings and concerns with supportive visitors.
Correct Answer is C
Explanation
A: Allowing the client to continue taking medications as they did at home without verifying the prescriptions can be unsafe and is not within the scope of nursing practice.
B: Taking the medications from the client and discarding them is inappropriate. The nurse should not dispose of the client's medications without proper assessment and verification.
C: Correct. The nurse should compare the medications the provider has prescribed with the medications the client brought from home to ensure accuracy and safety. This is a crucial step during admission to prevent errors or omissions in the medication regimen.
D: Placing the medications in the medication cart and administering them without verification is unsafe and against best practices for medication administration.
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