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?

Temperature 37.2°C (99°F).

Pulse rate 118/min.

Blood pressure 152/90 mm Hg.

Central venous pressure 25 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
A temperature of 37.2°C (99°F) is within the normal range (approximately 36.5°C to 37.5°C or 97.7°F to 99.5°F) and does not specifically indicate fluid volume deficit. It's important to consider this value along with other findings.
Choice B rationale:
(Correct Choice) A pulse rate of 118/min is indicative of tachycardia, which can be a sign of fluid volume deficit. When the body is experiencing a decrease in fluid volume, the heart rate often increases as a compensatory mechanism to maintain adequate circulation. Tachycardia helps to pump a reduced blood volume more rapidly to vital organs.
Choice C rationale:
A blood pressure of 152/90 mm Hg is elevated but does not solely indicate a fluid volume deficit. While low blood pressure can be a sign of dehydration, high blood pressure does not necessarily correlate directly with fluid volume status.
Choice D rationale:
Central venous pressure (CVP) of 25 mm Hg is elevated. CVP reflects the pressure in the vena cava and right atrium, indicating the amount of blood returning to the heart. An elevated CVP might be seen in fluid volume excess or right-sided heart failure, not fluid volume deficit.

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Correct Answer is B

Explanation

Choice A rationale:
Temperature 38.4°C (101.1°F) An elevated temperature could indicate an infection, which would not be a therapeutic response to total parenteral nutrition (TPN). TPN is provided to support the client's nutrition and help improve their condition; an elevated temperature might suggest ongoing illness.
Choice B rationale:
BMI 18.5 A BMI of 18.5 is considered within the normal range, indicating that the client's malnutrition is improving due to the TPN therapy. A higher BMI suggests a better nutritional status, which is a therapeutic response to the intervention.
Choice C rationale:
BUN 25 mg/dL Blood Urea Nitrogen (BUN) levels can be affected by various factors, including hydration status, renal function, and protein intake. While BUN levels might be monitored to assess renal function and overall nutritional status, a specific BUN level of 25 mg/dL does not directly indicate a therapeutic response to TPN.
Choice D rationale:
Hgb 10 g/dL Hemoglobin (Hgb) level of 10 g/dL is within the normal range for hemoglobin levels. Adequate nutrition, as provided by TPN, can support the production of red blood cells and maintain hemoglobin levels. Therefore, an Hgb level of 10 g/dL can be considered a positive therapeutic response to TPN.

A. Hyperventilation. B. Cool skin. C. Metallic taste. D. Anxiety.

Correct Answer is A

Explanation

Choice A rationale:
Hyperventilation, or rapid breathing, is a potential manifestation of hyperglycemia in clients with diabetes mellitus. As blood glucose levels rise, the body attempts to eliminate excess glucose through increased urination. This can lead to dehydration and electrolyte imbalances, potentially resulting in hyperventilation as the body tries to compensate for acidosis. The increased respiratory rate is an attempt to expel carbon dioxide and normalize pH levels. Teaching the client about the connection between hyperglycemia and hyperventilation is crucial, as recognizing this symptom can prompt early intervention.
Choice B rationale:
Cool skin is not a typical manifestation of hyperglycemia. Hyperglycemia usually leads to increased blood flow and warm skin due to the vasodilatory effects of high glucose levels. Cool skin might be more indicative of poor peripheral circulation, but it's not directly related to hyperglycemia.
Choice C rationale:
Metallic taste is not a recognized manifestation of hyperglycemia. Hyperglycemia primarily affects the body's glucose metabolism and can lead to symptoms like increased thirst, frequent urination, and fatigue. Metallic taste is not directly linked to hyperglycemia and might be related to other factors.
Choice D rationale:
Anxiety can be a psychological response to the stress of a new diabetes diagnosis, but it is not a specific manifestation of hyperglycemia. Hyperglycemia-related symptoms are more physiological and metabolic in nature, involving glucose regulation and acid-base balance.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has AIDS and is malnourished. The client has been receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a therapeutic response to the TPN?

Correct Answer is B

Explanation

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about recognizing hyperglycemia. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is A

Explanation

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