Exhibits
Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.
Which three of the following client findings indicate that the client may still have a fluid volume deficit?
Heart rate 99 beats/minute
Dark, yellow urine
Urinated 30 mL
Temperature 101° F (38.3° C)
Correct Answer : A,B,C
A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor is not directly related to low serum calcium levels. It may indicate anemia or other conditions, but it is not a primary concern for hypocalcemia.
B. Bruising is generally associated with clotting issues or trauma, not specifically with low serum calcium. Low calcium can affect clotting, but bruising is not a direct or primary symptom of hypocalcemia.
C. Tetany, which includes symptoms like muscle spasms, twitching, and numbness, is a key indicator of low serum calcium levels. Monitoring for tetany is essential in managing clients with malabsorption syndrome who have hypocalcemia.
D. Jaundice is a sign of liver dysfunction or hemolysis, not directly related to low calcium levels. Low serum calcium is not typically associated with jaundice.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Leaving an Older Adult in a Public Space
- Abandonment: Leaving the client alone in a public space can be considered abandonment, as it involves a failure to provide necessary care and supervision.
- Untreated Pressure Injuries
- Neglect: Untreated pressure injuries indicate a failure to provide adequate care and preventative measures, which is a form of neglect.
- Oversedation
- Physical Abuse: Administering excessive medication or sedation without proper medical justification can be a form of physical abuse.
- Poor Personal Hygiene
- Neglect: Poor personal hygiene often results from neglect, where the caregiver fails to assist with or encourage personal care practices.
- Depression or Withdrawn Behavior
- Neglect: Depression or withdrawn behavior can result from neglectful conditions, such as a lack of social interaction or emotional support.
- Bruises in Various Stages of Healing
- Physical Abuse: Bruises in various stages of healing are a classic sign of physical abuse, indicating that the client has been subjected to physical harm.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.