A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?

Dyspnea

Increased blood pressure

Weak pulse

Decreased heart rate

Answer and Explanation

The Correct Answer is C

A: Dyspnea, or difficulty breathing, can occur in various conditions but is not a primary manifestation of hypovolemia. Hypovolemia primarily affects the cardiovascular system due to reduced blood volume.

B: Increased blood pressure is not a typical manifestation of hypovolemia. In fact, hypovolemia usually leads to decreased blood pressure due to the reduced volume of circulating blood.

C: A weak pulse is a common manifestation of hypovolemia. The reduced blood volume leads to decreased cardiac output, resulting in a weak and thready pulse.

D: Decreased heart rate is not typical in hypovolemia. The body usually compensates for low blood volume by increasing the heart rate (tachycardia) to maintain adequate circulation.

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Correct Answer is C

Explanation

A: Identifying the type of sedative is important for treatment but is not the immediate priority.

B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.

C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.

D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.

A. Blood pressure 178/90 mm Hg B. Jugular vein distention C. Heart rate 50 D. Skin tenting present

Correct Answer is D

Explanation

A: Blood pressure of 178/90 mm Hg indicates hypertension, not dehydration. Dehydration typically leads to low blood pressure due to reduced blood volume.

B: Jugular vein distention is associated with fluid overload or heart failure, not dehydration. Dehydration usually results in flat neck veins.

C: A heart rate of 50 beats per minute is bradycardia and is not typically associated with dehydration. Dehydration often causes an increased heart rate (tachycardia) as the body tries to maintain adequate circulation.

D: Skin tenting present is a classic sign of dehydration. When the skin is pinched and does not return to its normal position quickly, it indicates a lack of fluid in the tissues.

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A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a sedative overdose. What is the priority action in caring for this client?

Correct Answer is C

Explanation

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Correct Answer is D

Explanation

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