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 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.
Correct Answer is A
Explanation
Bananas: Bananas are a suitable choice for a client taking digoxin and furosemide. Digoxin is a medication commonly prescribed for heart failure and certain heart rhythm disorders, and maintaining adequate potassium levels is important while taking this medication. Bananas are a good source of potassium and can help prevent or correct low potassium levels (hypokalemia), which can be a potential side effect of both digoxin and furosemide.
Green beans: Green beans can be included in the client's diet when taking digoxin and furosemide. While they are a healthy vegetable choice, they do not have a direct impact on the potassium levels affected by these medications.
Blueberries: Blueberries are a nutritious fruit choice, but they do not have a specific relevance to the client's medication regimen of digoxin and furosemide. They can be part of a balanced diet but are not specifically recommended or contraindicated in this context.
Cucumbers: Cucumbers are a refreshing vegetable choice, but they do not have a direct impact on the potassium levels affected by digoxin and furosemide. While maintaining hydration is important, other foods would be more relevant for addressing potassium needs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today