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 A
Explanation
A. Hoarseness in the voice following a thyroidectomy can be a sign of vocal cord damage or laryngeal nerve injury, which are potentially serious complications. The appropriate action is to notify the unit charge nurse to escalate the finding for further assessment by a physician or advanced practice provider.
B. Administering humidified oxygen does not specifically address the issue of hoarseness. While humidified oxygen might be beneficial for general respiratory comfort, it is not a targeted intervention for potential vocal cord damage.
C. Ensuring that the drainage device is compressed is important for managing surgical wounds but does not address or diagnose vocal cord issues. Hoarseness after thyroid surgery is more indicative of a potential complication rather than a drainage issue.
D. Obtaining ice chips does not address the underlying cause of the hoarseness and may not provide significant relief. The priority is to identify potential complications rather than offering symptomatic relief.
Correct Answer is B
Explanation
A. NSAIDs are not associated with the characteristic features of truncal obesity, moon face, and buffalo hump.
B. Corticosteroids can cause truncal obesity, moon face, and buffalo hump as side effects due to their effects on metabolism and fat distribution.
C. Thyroid replacement hormone is used to treat hypothyroidism and does not cause the symptoms described.
D. Insulin is used to manage diabetes and does not typically cause the features seen in Cushing’s syndrome associated with corticosteroid use.
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.