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. Discontinued medications are documented in the medical record but are not the primary focus of the transfer report.
B. Resolved health conditions should be included in the transfer report so the receiving facility has a clear understanding of the client’s current health status and any changes in care needs.
C. Frequency of vital sign collection is part of ongoing care but is not the most critical information to communicate during transfer.
D. Completed nursing interventions are documented in the record but do not need to be emphasized in the transfer report.
Correct Answer is ["1820"]
Explanation
1. IV fluids:
- 150 mL/hr * 8 hr = 1200 mL
2. Juice:
- 4 oz * 30 mL/oz = 120 mL
3. Water:
- 0.5 L * 1000 mL/L = 500 mL
Total intake:
- 1200 mL + 120 mL + 500 mL = 1820 mL
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