A nurse is assessing a client. Which of the following findings indicates a fluid volume deficit?
Pitting edema
Elevated blood pressure
Dyspnea
Skin tenting
The Correct Answer is D
A. Pitting edema: Pitting edema indicates fluid volume excess, not deficit. It occurs when excess interstitial fluid accumulates and is compressed, leaving a visible indentation.
B. Elevated blood pressure: Elevated blood pressure is commonly associated with fluid volume excess or other cardiovascular conditions. Hypovolemia typically presents with low blood pressure due to decreased circulating volume.
C. Dyspnea: Dyspnea is more indicative of fluid overload, pulmonary edema, or cardiac issues rather than fluid volume deficit. It is not a primary sign of hypovolemia.
D. Skin tenting: Skin tenting reflects decreased skin turgor, a classic sign of fluid volume deficit. It occurs because dehydration reduces the elasticity of the skin, causing it to remain elevated when pinched.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Blurred vision: Blurred vision is not a common adverse effect of cefaclor. Visual disturbances are typically unrelated to cephalosporin therapy, so monitoring for this symptom is not a priority during treatment.
B. Diarrhea: Diarrhea is a known adverse effect of cefaclor due to its impact on gut flora, which can lead to mild gastrointestinal upset or, in severe cases, antibiotic-associated colitis. Monitoring for changes in bowel patterns helps detect complications early and guide intervention.
C. Hypoglycemia: Hypoglycemia is not typically associated with cefaclor use. Cephalosporins do not directly affect blood glucose regulation, so routine glucose monitoring is not required unless the client has other risk factors, such as concurrent insulin therapy.
D. Photosensitivity: While some antibiotics (like tetracyclines or fluoroquinolones) can cause photosensitivity, it is not a primary or common adverse effect of cefaclor.
Correct Answer is A
Explanation
A. Provide analgesic medication prior to physical activities: Administering opioids before ambulation or physical therapy helps control pain, allowing the client to participate in activities that prevent complications such as atelectasis, venous thromboembolism, and delayed mobility. This approach supports recovery and promotes functional independence.
B. Administer naloxone if the client's respiratory rate is greater than 24/min.: Naloxone is used to reverse opioid-induced respiratory depression, which occurs at low respiratory rates, not elevated rates. A respiratory rate above 24/min may indicate pain, anxiety, or other issues, but it does not warrant naloxone administration.
C. Inform the client to monitor for loose stools while taking opioid analgesia: Opioids commonly cause constipation rather than diarrhea. Clients should be advised to monitor for constipation and use preventive measures such as adequate hydration, dietary fiber, or stool softeners.
D. Withhold analgesic medication unless the client reports pain: Waiting for the client to report pain can allow pain to become severe, making it harder to manage and potentially limiting mobility. Scheduled or pre-activity dosing is preferred to maintain comfort and facilitate recovery.
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