A nurse in a critical care unit is assessing an adult client. Which of the following findings by the nurse indicates a fluid volume deficit?
Heart rate 118/min
Central venous pressure 25 mm Hg
Blood pressure 152/90 mm Hg
Temperature 37.2° C (99° F)
The Correct Answer is A
A. A heart rate of 118/min suggests tachycardia, which is a compensatory mechanism in response to fluid volume deficit. The body increases heart rate to maintain cardiac output when fluid volume is low.
B. A central venous pressure of 25 mm Hg may indicate fluid volume overload rather than deficit. It suggests increased venous pressure, possibly due to excess fluid.
C. A blood pressure of 152/90 mm Hg is within the normal range and does not specifically indicate fluid volume deficit.
D. A temperature of 37.2°C (99°F) is within the normal range and does not specifically indicate fluid volume deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- Rationale for A: One slice of bread typically does not equate to 1 oz of protein. Bread is primarily a source of carbohydrates and contains only a small amount of protein, making it insufficient to meet the protein equivalent of 1 oz.
- Rationale for B: Two tablespoons of peanut butter have approximately 8 grams of protein, which is close to the protein content of 1 oz of meat. However, it is slightly less than the standard 1 oz protein equivalent, which is about 7 grams of protein, as found in one egg.
- Rationale for C: One scrambled egg is equivalent to 1 oz of protein because it contains approximately 7 grams of protein, which aligns with the protein content of 1 oz of meat. Eggs are a complete protein source, providing all the essential amino acids needed by a toddler.
- Rationale for D: Half a cup of peas contains about 4 grams of protein, which is less than the 7 grams found in 1 oz of meat or one egg. Therefore, 1/2 cup of peas does not meet the equivalent of 1 oz of protein.
Correct Answer is B
Explanation
Choice A Rationale: Vitamin A is essential for healthy skin, hair, nails, and bones, and acts as an antioxidant. However, excessive amounts can be harmful and even modest doses previously considered safe can increase the risk of fracture.
Choice B Rationale: Fortified milk, fatty fish, and cheese are rich in calcium and vitamin D, which are crucial for bone health. Calcium is necessary for bone strength, while vitamin D is required for calcium absorption in the body.
Choice C Rationale: While a calcium supplement can help maintain bone density and reduce the risk of fractures, it is generally recommended to get calcium from dietary sources for better absorption and additional nutrients.
Choice D Rationale: Orange juice, lean meats, and egg whites can contribute to overall health, but they do not directly address bone health as effectively as options rich in calcium and vitamin D. Orange juice can be beneficial if fortified, but lean meats and egg whites are not primary sources of calcium or vitamin D.
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