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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B: Eggs.
Choice B rationale: Most influenza vaccines are manufactured using egg-based technology and contain trace amounts of egg proteins, such as ovalbumin. Individuals with egg allergies may potentially experience allergic reactions to these proteins. While current guidelines recommend that individuals with egg allergies can still receive the inactivated influenza vaccine under the supervision of a healthcare provider, it is crucial to screen for egg allergies to ensure appropriate precautions are taken during vaccine administration.
Choice A rationale: Although shellfish allergies can cause severe reactions in some individuals, they are not specifically associated with the production or components of the inactivated influenza vaccine. Therefore, inquiring about shellfish allergies would not directly help determine the risk of an adverse reaction to the influenza vaccine.
Choice C rationale: Citrus fruit allergies are not directly related to the components or production methods of the inactivated influenza vaccine. While it is essential to be aware of a patient's allergy history, asking about citrus fruit allergies would not be the most relevant question in this context.
Choice D rationale: Gelatin allergies may be relevant in the administration of certain vaccines, as some contain gelatin as a stabilizer. However, the primary allergenic component of concern in the inactivated influenza vaccine is egg protein, not gelatin. Therefore, asking about gelatin allergies would not be the priority when assessing potential allergic reactions to the influenza vaccine.
Correct Answer is C
Explanation
Choice A rationale:
Maintaining a low-protein diet is not the appropriate instruction for a client taking a monoamine oxidase inhibitor (MAOI). While dietary restrictions are associated with MAOIs, it's primarily focused on avoiding foods rich in tyramine, which is not limited to just protein-containing foods.
Choice B rationale:
Not eating grapefruit while taking medication is generally applicable advice, but it is not specific to MAOIs. Grapefruit can interfere with the metabolism of certain medications by inhibiting specific enzymes. However, it's not a concern solely related to MAOIs.
Choice C rationale:
Avoiding aged cheeses while taking this medication is the correct instruction. Aged cheeses contain tyramine, which can lead to a hypertensive crisis when consumed with MAOIs. Tyramine interacts with MAOIs to increase blood pressure, potentially causing a serious reaction.
Choice D rationale:
Reducing intake of high-calorie foods is not a primary concern when taking MAOIs. The main dietary focus is on avoiding tyramine-rich foods to prevent dangerous interactions. High-calorie foods are not directly contraindicated with MAOIs.
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