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 B
Explanation
A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.
Correct Answer is ["B","C"]
Explanation
A. A broken arm from a volleyball game is an injury that is not necessarily indicative of family violence; it appears to be an accident.
B. Multiple old fractures in a young child may indicate possible abuse or family violence, as this pattern is concerning for potential neglect or physical harm.
C. Multiple bruises on the hands and face of a married man may suggest a pattern of domestic violence, which should be reported for further assessment.
D. Soiled clothing and foul body odor may indicate poor living conditions but are not specific indicators of family violence.
E. A skull fracture from an automobile collision is likely an accident, not necessarily indicative of family violence unless further evidence suggests abuse.
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