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 D
Explanation
Choice A rationale:
Cheddar cheese does not contain a significant amount of potassium. It is a dairy product that is richer in calcium and fat than in potassium.
Choice B rationale:
Raw tomato contains some potassium, but it's not as high as the other options. It's a good source of vitamins and antioxidants, but for hypokalemia, more potassium-rich options are better.
Choice C rationale:
Brown rice contains moderate levels of potassium, but it is not as high as the potassium content in a baked potato.
Choice D rationale:
One small baked potato is a great source of potassium. Potatoes are known for their high potassium content, making them suitable for individuals with hypokalemia, as potassium is essential for proper muscle and nerve function.
Correct Answer is C
Explanation
Choice A rationale:
Cucumbers Cucumbers are not relevant to the client's medication regimen. There is no specific interaction between cucumbers and digoxin or furosemide that would require their consumption or avoidance.
Choice B rationale:
Blueberries Similarly, blueberries do not have any specific interaction with digoxin or furosemide. They are not a necessary or contraindicated food item for this client.
Choice C rationale:
Bananas The nurse should instruct the client to consume bananas. Bananas are a good dietary source of potassium. Furosemide is a loop diuretic that can cause potassium depletion, so it's important for the client to maintain adequate potassium levels. Digoxin can also affect potassium levels, potentially leading to an increased risk of digoxin toxicity if potassium is too low. Including potassium-rich foods like bananas can help mitigate these risks and maintain proper electrolyte balance.
Choice D rationale:
Green beans While green beans are a nutritious vegetable, they do not have a direct relevance to the client's medication regimen. They are not specifically indicated or contraindicated in the context of digoxin and furosemide use.
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