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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
Correct Answer is A
Explanation
A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.
B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.
C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.
D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.
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