A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Increased blood pressure

Thready pulse

Dyspnea

Decreased heart rate

Answer and Explanation

The Correct Answer is B

A. Increased blood pressure: Hypovolemia typically causes a decrease in blood pressure, not an increase.
B. Thready pulse: A thready pulse is a common sign of hypovolemia due to decreased blood volume.
C. Dyspnea: While dyspnea can occur, it is not as specific as a thready pulse for hypovolemia.
D. Decreased heart rate: Hypovolemia usually causes an increased heart rate as the body tries to compensate for low blood volume.

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Correct Answer is C

Explanation

A. Lipids: A guaiac test does not detect lipids. It is specifically designed to detect occult (hidden) blood.
B. Bacteria: The guaiac test does not detect bacteria; stool cultures are used for this purpose.
C. Blood: The guaiac test is used to detect the presence of occult blood in the stool, which can indicate gastrointestinal bleeding.
D. Bile: The guaiac test does not detect bile; other tests and observations are used for bile in stool.

A. Allow the client to expel some fluid before continuing. B. Encourage the client to bear down. C. Stop the enema and document that the client did not tolerate the procedure. D. Lower the height of the solution container.

Correct Answer is D

Explanation

A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.

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A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is D

Explanation

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