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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to eat even if nauseated may worsen nausea and discomfort. It's essential to respect the client's feelings of nausea and provide strategies to alleviate symptoms before eating.
B. Serving hot foods at mealtime may exacerbate nausea in some individuals. It's generally recommended to serve foods at room temperature or slightly chilled to minimize nausea.
C. Providing low-fat carbohydrates with meals, such as crackers or bread, can help settle the stomach and provide easily digestible energy. Complex carbohydrates are less likely to exacerbate nausea compared to fatty or spicy foods.
D. Limiting fluid intake between meals may help reduce nausea in some individuals, but it's important to ensure adequate hydration throughout the day. Encouraging small, frequent sips of clear fluids may be beneficial for managing nausea and preventing dehydration.
Correct Answer is ["B","E"]
Explanation
A. Removing the bedpan from the client's sight is not directly related to addressing malnutrition risk.
B. Assessing for pain prior to mealtime is important because pain can interfere with appetite and eating, contributing to malnutrition.
C. Administering antiemetics following the meal may address nausea or vomiting, but it does not address the underlying factors contributing to malnutrition.
D. Discouraging snacks between meals may not be appropriate for all clients at risk for malnutrition, especially if they have poor oral intake during meals. Snacks may be necessary to provide additional nutrition and calories.
E. Providing mouth care before feeding helps improve oral hygiene, which can enhance the client's appetite and ability to eat.
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