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 D

Explanation

A. Use the dominant hand to pinch the client's skin: The dominant hand is used to inject the medication, while the non-dominant hand is used to pinch the skin.
B. Don sterile gloves prior to the injection. Clean gloves, not sterile gloves, are appropriate for subcutaneous injections.
C. Inject the medication at a 15° angle to the client's skin: Subcutaneous injections are typically given at a 45° or 90° angle, not 15°.
D. Cleanse the injection site with a circular motion. This is the correct technique to ensure the injection site is clean.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To confirm the placement of the NG tube D. To determine the client's electrolyte balance

Correct Answer is B

Explanation

not to remove gastric acid but to assess tolerance to feedings.
B. To identify delayed gastric emptying: Measuring gastric residual volume helps identify delayed gastric emptying, which can indicate a risk of aspiration or intolerance to the feeding.
C. To confirm the placement of the NG tube: Tube placement should be confirmed by other means, such as pH testing or X-ray, rather than measuring residual.
D. To determine the client's electrolyte balance: Measuring gastric residual does not provide information about the client's electrolyte balance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is B

Explanation

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