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","C","D"]
Explanation
A. Gloves
Gloves are essential when entering the room because MRSA (Methicillin-resistant Staphylococcus aureus) is a pathogen that can be transmitted through direct contact with contaminated surfaces or secretions. Gloves protect both the client and the PN from the spread of the infection and should be worn when touching the patient or surfaces/items in the room.
B. N95 Mask
An N95 mask is not required for MRSA infections unless there are concerns about airborne transmission, which is not typical for MRSA. MRSA transmission is primarily through direct or indirect contact rather than airborne routes, so an N95 mask is not necessary in this scenario.
C. Gown
A gown is required when there is a risk of contamination from the environment or the patient, especially with MRSA infections. It helps to protect the PN’s clothing and skin from coming into contact with any infectious materials from the surgical site.
D. Surgical Mask
A surgical mask is appropriate for MRSA to protect against droplets and to prevent the spread of infection. It is particularly useful if there is a risk of droplets from the patient or if the PN is performing procedures that might generate droplets.
E. Goggles
Goggles are not required for MRSA unless there is a specific risk of splash or spray that could potentially expose the PN’s eyes to infectious materials. In the context of a surgical site infection, goggles are not a standard part of the PPE unless additional procedures are being performed that involve splashes
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Applicable
Evaluating functional improvement assesses whether the additional physical and occupational therapy is effectively enhancing the client’s ability to perform activities of daily living and participate in community activities. This focuses on tangible outcomes of the therapy, such as improved mobility or independence. Measuring functional improvement helps to determine if the interventions are meeting their goals and positively impacting the client's physical abilities.
Psychological assessment
Not Applicable
While important, psychological assessment is not the primary focus when evaluating the specific outcomes of physical and occupational therapy. Psychological well-being might be a component of overall care but is not the immediate measure for the success of the physical therapies established. The main goal here is to assess the effectiveness of the physical and occupational therapy, which is more directly measured by functional and quality of life improvements.
Quality of life
Applicable
Assessing quality of life evaluates how well the client’s overall well-being is supported by the new care interventions, including their physical comfort, mental health, and ability to engage in daily activities. This broader measure considers whether the care provided enhances the client's satisfaction with their daily life and personal experiences, reflecting the success of the implemented therapies.
Financial security
Not Applicable
Financial security is not directly related to evaluating the outcomes of physical and occupational therapy interventions. It is important for overall care management but does not measure the effectiveness of specific therapies or the impact on the client’s physical functioning or quality of life. This factor is outside the scope of assessing the direct results of therapy and daily living support.
Cognitive status
Not Applicable
Cognitive status is not the main focus for evaluating the success of physical and occupational therapy. While cognitive status is relevant for overall care, the immediate goal of assessing the effectiveness of the physical therapies is to see improvements in functional abilities and quality of life. Cognitive assessments are important but not directly related to the specific goals of physical and occupational therapy outcomes
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