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 C

Explanation

A. Remove dentures:

Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.

B. Apply a shroud around the body with a visible identification tag:

Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.

C. Clean soiled areas of the body:

This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.

D. Place the client's head in a dependent position:

Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.

A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years.

Correct Answer is A

Explanation

A: Correct. Regular dental assessments every 6 months are recommended for all individuals, including young adults, to maintain good oral health and detect any potential issues early.
B: Incorrect. Testicular examinations are important for young adult males, but they should be performed monthly as part of testicular self-examination, not every 5 years.
C: Incorrect. Young adult females should have a routine physical examination annually, not every 4 years, to monitor their overall health and address any potential health concerns.
D: Incorrect. While tuberculosis screening is essential in certain populations, such as healthcare workers or individuals at high risk of exposure, a tuberculosis skin test every 3 years is not a standard recommendation for all young adults.

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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

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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