A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?

Weak pulse

Distended neck veins

Bradycardia

Pitting Edema

Answer and Explanation

The Correct Answer is A

A. Weak pulse: Isotonic fluid-volume deficit results in decreased blood volume, leading to reduced cardiac output and a weak, thready pulse.

B. Distended neck veins: This is associated with fluid volume excess, not deficit.

C. Bradycardia: Fluid deficit typically leads to tachycardia as the body compensates for decreased circulating volume.

D. Pitting edema: This is a sign of fluid overload rather than deficit.

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Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

A. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate. B. Restrict fluid intake. C. Obtain a 12-lead ECG. D. Administer potassium gluconate 40 mEq orally.

Correct Answer is C

Explanation

A. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate (ESR): ESR measures inflammation and is unrelated to hyperkalemia.

B. Restrict fluid intake: Fluid restriction is not appropriate for hyperkalemia unless specifically related to fluid overload or renal failure.

C. Obtain a 12-lead ECG: Hyperkalemia can cause life-threatening cardiac dysrhythmias such as peaked T waves, widened QRS complexes, or asystole. ECG monitoring is essential.

D. Administer potassium gluconate 40 mEq orally: This would worsen hyperkalemia and is contraindicated.

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A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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