The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia?

A patient who lost 2 liters of blood during surgery

A patient who received 6 liters of IV fluid

A patient with UTI on po iv meds

A patient with congestive heart failure

Answer and Explanation

The Correct Answer is A

A. A patient who lost 2 liters of blood during surgery: This is the most acute and severe form of hypovolemia due to significant blood loss, requiring immediate fluid replacement and hemodynamic monitoring.

B. A patient who received 6 liters of IV fluid: This patient is at risk for hypervolemia, not hypovolemia, due to fluid overload.

C. A patient with UTI on PO meds: While dehydration may occur, it is typically mild and does not cause hypovolemia.

D. A patient with congestive heart failure: CHF usually leads to fluid retention, making hypovolemia unlikely unless there are other complicating factors.

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Correct Answer is C

Explanation

A. BP 178/90 mm Hg: High blood pressure can be seen in various conditions, including stress or pain. Dehydration typically leads to low blood pressure, not high, making this less likely to be an indicator of dehydration.

B. Red mucous membranes: Red mucous membranes can indicate a variety of conditions, including infection or inflammation, but it is not a classic sign of dehydration.

C. Skin tenting: Skin tenting, or the inability of the skin to return to normal after being pinched, is a classic sign of dehydration, particularly in moderate to severe cases. This indicates reduced skin turgor and is directly related to fluid volume depletion.

D. Jugular vein distention: Jugular vein distention is more indicative of fluid overload or increased central venous pressure, not dehydration.

A. Skeletal muscle weakness B. Decreased deep-tendon reflexes C. Tingling of the lips D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. Skeletal muscle weakness: This is more commonly seen with hypercalcemia, not hypocalcemia. Hypocalcemia typically causes neuromuscular irritability, which manifests as muscle spasms rather than weakness.

B. Decreased deep-tendon reflexes: This is more commonly seen with hypercalcemia. Hypocalcemia typically increases neuromuscular irritability and can cause hyperactive reflexes.

C. Tingling of the lips: This is a classic sign of hypocalcemia, as low calcium levels can lead to neuromuscular excitability, which can cause sensations like tingling (paresthesia) around the lips and fingers.

D. Hypoactive bowel sounds: Hypocalcemia typically increases bowel motility, which can lead to hyperactive bowel sounds, not hypoactive bowel sounds.

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The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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