A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?

Decreased hematocrit

Increased urine ketones

Increased urine specific gravity

Decreased BUN

Answer and Explanation

The Correct Answer is C

A.   Hematocrit measures the percentage of red blood cells in the blood. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, resulting in an increase in hematocrit rather than a decrease. Therefore, a decreased hematocrit would not be an expected finding in fluid volume deficit.
B.   Urine ketones are typically elevated in conditions where there is increased fat metabolism, such as in diabetic ketoacidosis or starvation. They are not directly related to fluid volume deficit and would not be an expected finding.
C.   Urine specific gravity measures the concentration of solutes in the urine, indicating the kidney's ability to concentrate or dilute urine. In fluid volume deficit, the body conserves water, leading to increased urine concentration and higher urine specific gravity. Therefore, increased urine specific gravity is an expected finding in fluid volume deficit.
D.   BUN is a measure of kidney function and protein metabolism. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, which can lead to an increase in BUN rather than a decrease. A decreased BUN would not typically be an expected finding in fluid volume deficit.

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Correct Answer is A

Explanation

A. Agitation can be a manifestation of hypoxia. As the body senses inadequate oxygen supply, it may respond with restlessness or agitation as a compensatory mechanism to increase oxygen intake.
B. Nausea is not a typical finding in hypoxia.
C. Dysphagia refers to difficulty swallowing and is not typically associated with hypoxia. It is more commonly related to neurological or structural issues affecting the swallowing mechanism.
D. Warm, dry skin is not a typical manifestation of hypoxia. In fact, hypoxia often results in cool, clammy, or cyanotic (bluish) skin due to inadequate oxygen perfusion.

A. Encourage the client to cough and deep breathe. B. Obtain the client's temperature. C. Encourage the client to increase oral fluids. D. Provide chest percussion on the client.

Correct Answer is A

Explanation

A. This action helps the client to clear pulmonary secretions and improve ventilation. Coughing and deep breathing exercises are essential for maintaining airway patency and preventing complications such as atelectasis and respiratory distress.
B. Monitoring the client's temperature is important to assess for fever, which can indicate infection severity or response to treatment. However, in a client actively coughing up secretions, immediate interventions to promote airway clearance take precedence over obtaining temperature.
C. Adequate hydration can help liquefy pulmonary secretions, making them easier to expectorate. However, this action is secondary to promoting effective coughing and deep breathing to clear secretions already present in the airways.

D. Chest percussion can help loosen and mobilize secretions in the lungs. However, this intervention requires assessment of the client's respiratory status and may not be appropriate as the first action without first assessing the client's tolerance and condition.

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A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?

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Naxlex Comprehensive Predictor Exams

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