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 B
Explanation
A. The DASH diet recommends limiting sodium intake to 2,300 milligrams per day for most individuals and further reducing it to 1,500 milligrams per day for those with hypertension or at high risk for it. Therefore, the instruction to limit sodium intake to 3,200 milligrams per day is not consistent with DASH diet recommendations.
B. The DASH diet emphasizes consumption of foods rich in calcium, such as low-fat dairy products, as part of its overall approach to promoting heart health and lowering blood pressure.
C. The DASH diet encourages consumption of whole grains and limits intake of refined carbohydrates, as these can contribute to hypertension and other cardiovascular risk factors.
D. The DASH diet recommends limiting saturated fat intake to less than 6% of total calories, rather than ten percent, as part of its emphasis on heart-healthy eating patterns.
Correct Answer is A
Explanation
A. Limiting protein intake is important for individuals with chronic kidney disease to reduce the workload on the kidneys and minimize the accumulation of waste products in the blood. High protein intake can accelerate the progression of kidney damage.
B. Increasing phosphorus intake is not recommended for individuals with chronic kidney disease, as impaired kidney function can lead to elevated phosphorus levels in the blood, which can contribute to complications such as bone disease and cardiovascular issues.
C. Increasing potassium intake is typically not advised for individuals with chronic kidney disease, especially if they have elevated potassium levels (hyperkalemia), as this can further stress the kidneys and increase the risk of cardiac arrhythmias.
D. Limiting calcium intake may be necessary for individuals with certain types of kidney stones, but it is not a general recommendation for all individuals with chronic kidney disease. In fact, calcium is important for bone health, and individuals with chronic kidney disease are at
increased risk of bone mineral disorders.
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