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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use sterile water to inflate the balloon: There is no balloon in a straight catheterization; this applies to indwelling catheters.
B. Use a sterile specimen container: A sterile specimen container ensures that the sample is not contaminated.
C. Instruct the client to clean from front to back with an antiseptic solution: This is relevant to midstream urine collection but not for straight catheterization.
D. Collect urine from the catheter's port. In straight catheterization, urine is collected directly as it exits the catheter, not from a port.
Correct Answer is B
Explanation
A. "You can expect fecal output within 24 hours." Fecal output usually occurs within 2-4 days after surgery, not within 24 hours.
B. "You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma is normal, especially right after surgery.
C. "You can expect the stoma to be purplish in color for the first week." A healthy stoma should be pink to red. A purplish color could indicate poor blood supply and should be reported.
D. "You will need to increase your dietary intake of raw vegetables." Raw vegetables can cause gas and obstruction; clients are usually advised to avoid them initially.
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