A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?
Decreased heart rate
Increased blood pressure
Weak pulse
Dyspnea
The Correct Answer is C
Choice A reason: Decreased heart rate is not a manifestation of hypovolemia. Hypovolemia is a condition where there is a decreased volume of blood in the body, which can result from blood loss, dehydration, or fluid shifts. Hypovolemia can cause the heart rate to increase, not decrease, as the body tries to compensate for the low blood pressure and maintain adequate perfusion.
Choice B reason: Increased blood pressure is not a manifestation of hypovolemia. Hypovolemia can cause the blood pressure to decrease, not increase, as the blood volume and cardiac output are reduced. The body may try to constrict the blood vessels to increase the blood pressure, but this is usually not enough to overcome the effects of hypovolemia.
Choice C reason: Weak pulse is a manifestation of hypovolemia. Hypovolemia can cause the pulse to become weak, thready, or difficult to palpate, as the blood flow and pressure are diminished. The pulse may also become irregular or rapid, as the heart tries to pump faster and harder to deliver oxygen to the tissues.
Choice D reason: Dyspnea is not a specific manifestation of hypovolemia. Dyspnea is a term for difficulty breathing, which can have many causes, such as asthma, pneumonia, or pulmonary edema. Hypovolemia can cause dyspnea if it leads to shock, which is a life-threatening condition where the organs and tissues are not receiving enough oxygen. However, dyspnea alone is not enough to indicate hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Mental alertness is not affected by the administration of hypertonic solutions. Hypertonic solutions are fluids that have a higher concentration of solutes than the blood. They draw water out of the cells and into the blood vessels, increasing the blood volume and osmolarity.
Choice B reason: Decreased pulse is not a result of administering hypertonic solutions too quickly. On the contrary, hypertonic solutions can increase the pulse rate as they increase the blood volume and pressure.
Choice C reason: Decreased blood pressure is not a consequence of administering hypertonic solutions too quickly. Hypertonic solutions can raise the blood pressure as they increase the blood volume and osmolarity.
Choice D reason: Fluid overload is the correct answer. Administering hypertonic solutions too quickly can cause fluid overload, which is a condition where the body has too much fluid in the blood vessels. This can lead to symptoms such as edema, dyspnea, crackles, and weight gain. Fluid overload can also cause heart failure, pulmonary edema, and cerebral edema.
Correct Answer is B
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client should avoid alcohol and other substances that can harm the liver, as adalimumab can increase the risk of liver toxicity and hepatitis.
Choice B reason: This is a statement that indicates a need for further teaching. The client should not take naproxen and aspirin as needed for pain relief, as these are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding and gastrointestinal ulcers. Adalimumab can also increase the risk of bleeding and ulcers, as it suppresses the immune system and the inflammatory response.
Choice C reason: This is not a statement that indicates a need for further teaching. The client should report any signs of infection or fever to the doctor, as adalimumab can increase the risk of serious infections and sepsis. Adalimumab can also mask the symptoms of infection, such as inflammation and pain.
Choice D reason: This is not a statement that indicates a need for further teaching. The client should inject the medication under the skin of the abdomen or thigh, as this is the recommended route and site for adalimumab administration.
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