A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
Bradycardia
Oliguria
Peripheral edema
Hypotension
The Correct Answer is C
A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.
B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.
C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.
D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.
B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.
C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.
D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.
Correct Answer is C
Explanation
A. Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.
B. Avoids using the fingers of her dominant hand as puncture sites:While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.
C. Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.
D. Avoids using the thumbs as puncture sites:
Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.
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