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?
Pulse rate 118/min
Blood pressure 152/90 mm Hg
Temperature 37.2° C (99° F)
Central venous pressure 25 mm Hg
The Correct Answer is A
A. Pulse rate of 118/min: In a client with fluid volume deficit, the pulse rate often increases as the body compensates for reduced blood volume.
B. Blood pressure of 152/90 mm Hg: This blood pressure reading does not specifically indicate fluid volume deficit as it can be influenced by various factors, including vascular tone and cardiac function.
C. Temperature of 37.2° C (99° F): This temperature reading is within the normal range and does not directly reflect fluid volume status.
D. Central venous pressure 25 mm Hg: This is elevated and typically suggests fluid volume excess rather than deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Iron deficiency can have various manifestations, but one of the significant effects is its impact on cognitive function. Iron is essential for the proper functioning of the brain and nervous system. In children, iron deficiency can lead to lowered intellectual performance, including difficulties with concentration, learning, memory, and problem-solving skills. It can also affect overall cognitive development and academic performance.
The other options listed are not typically associated with iron deficiency:
"Elevated temperature": Elevated temperature or fever is not a direct manifestation of iron deficiency. Fever is commonly associated with infections, inflammatory conditions, or other illnesses, but not specifically with iron deficiency.
"Decreased sleeping time": While iron deficiency can cause various symptoms, changes in sleep patterns, such as decreased sleeping time, are not a typical manifestation. Iron deficiency may cause fatigue and general weakness, which could potentially impact sleep quality and duration, but it is not directly associated with decreased sleeping time.
"Increased risk of infection": Iron deficiency can affect the immune system, making individuals more susceptible to infections. However, an increased risk of infection is a consequence of impaired immune function rather than a direct manifestation of iron deficiency itself.
Correct Answer is C
Explanation
The nurse should plan to change the IV tubing for the TPN solution every 72 hours. This is necessary to maintain the sterility of the system and minimize the risk of infection. TPN solutions are prone to bacterial growth, and changing the tubing regularly helps prevent contamination.
Removing TPN from the refrigerator 5 minutes before infusing it is not necessary. TPN solutions are typically stored in the refrigerator to maintain their stability and prevent spoilage. It should be brought to room temperature over a longer period of time, usually 30-60 minutes, before administration.
Discarding the remaining TPN solution that is still infusing after 24 hours is unnecessary. TPN solutions can typically be infused for up to 24 hours without compromising their safety and efficacy. However, it is important to monitor the solution closely for any signs of contamination or degradation, and if any concerns arise, the nurse should consult with the healthcare provider.
Changing the dressing around the IV site weekly is not specific to TPN administration. Dressing changes for peripheral IV sites are typically performed according to facility protocols and the condition of the site, but they are not necessarily done on a weekly basis. The frequency of dressing changes depends on factors such as the type of dressing used, the patient's condition, and any signs of infection or dislodgement.
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