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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Peripheral pulses +1: Weak peripheral pulses indicate continued hypovolemia or dehydration. Effectiveness would be reflected in stronger pulses.
B. Urine output 200 mL/4 hr: Adequate urine output (≥30 mL/hr) indicates improved kidney perfusion and hydration status, suggesting effective treatment.
C. Urine specific gravity 1.04: This value is elevated, indicating continued dehydration; effective hydration would reduce this value to the normal range of 1.005-1.030.
D. Heart rate 104/min: Tachycardia is a compensatory response to dehydration. Improvement would manifest as a normalized heart rate (60-100 bpm).
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Answer: I. Temperature
II. Antibiotic therapy
I. Temperature: The client has a fever (37.3°C), which can be a sign of infection or another serious condition. The first priority is to address the fever, as it may indicate a systemic infection, which needs immediate intervention. Fever is usually managed with antipyretics such as acetaminophen.
II. Antibiotic therapy: Since the client has a fever and possible infection, antibiotic therapy should be initiated early (as per the provider’s orders) to treat the suspected infection. Broad-spectrum antibiotics are often started while waiting for culture results.
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