A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
(Select All that Apply.)
Bradycardia
Pale Yellow Urine
Poor Skin Turgor
Hypotension
Flat Neck Veins
Correct Answer : C,D,E
A. Bradycardia: Vomiting and diarrhea usually lead to tachycardia (increased heart rate) as the body compensates for hypovolemia, not bradycardia (slow heart rate).
B. Pale Yellow Urine: Dehydration often causes the urine to become concentrated and dark yellow, not pale yellow.
C. Poor Skin Turgor: Poor skin turgor is a classic sign of dehydration caused by fluid loss.
D. Hypotension: Loss of fluid volume can result in hypotension due to reduced blood circulation.
E. Flat Neck Veins: Dehydration causes reduced venous return, leading to flat neck veins, particularly when lying down.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The patient can experience speed shock: Speed shock is a rapid infusion of a substance (like a medication or fluid) into the bloodstream, usually occurring when the infusion rate is too fast. This is not typically caused by flushing a clotted cannula.
B. A clot can be forced into the circulation causing serious complications: Flushing a clotted cannula too aggressively can dislodge a clot, causing it to travel into the bloodstream. This can lead to serious complications like embolism or stroke, especially if the clot is large or travels to a vital organ.
C. A painful arterial spasm can occur: While arterial spasms can occur, they are more often related to arterial catheterization or manipulation rather than flushing a venous cannula.
D. The catheter can become dislodged and fall out: While this could potentially happen, it is less of a concern compared to the risk of pushing a clot into circulation, which is a more immediate danger.
Correct Answer is A
Explanation
A. 0.9% sodium chloride: Normal saline (0.9% sodium chloride) is the standard solution that can be administered with blood products. It is isotonic and does not cause hemolysis or alter the structure of red blood cells.
B. Lactated Ringers solution: Lactated Ringers solution is not used with blood products due to the potential for hemolysis when calcium is present, which can interfere with the clotting cascade and affect blood cell integrity.
C. 5% dextrose/0.2% sodium chloride: Dextrose solutions should not be used with blood components, as they can cause red blood cells to hemolyze, leading to hemolysis and complications in transfusion.
D. 5% dextrose/0.45% sodium chloride: This solution contains dextrose, which can cause red blood cell hemolysis and should not be used with blood products.
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