A nurse is assessing a client. Which of the following findings indicates a fluid volume deficit?
Pitting edema
Skin tenting
Elevated blood pressure
Dyspnea
The Correct Answer is B
Rationale:
A. Pitting edema: Pitting edema typically indicates fluid volume excess, not deficit. It occurs when there is an accumulation of fluid in the interstitial spaces, causing swelling that leaves an indentation when pressed.
B. Skin tenting: Skin tenting is a common sign of fluid volume deficit, particularly dehydration. It occurs when the skin loses elasticity due to a lack of adequate hydration, causing the skin to remain "tented" when pinched.
C. Elevated blood pressure: Elevated blood pressure is more commonly associated with fluid volume excess, not deficit. Increased fluid volume can lead to higher blood pressure due to greater circulating volume and increased vascular resistance.
D. Dyspnea: Dyspnea, or difficulty breathing, is a symptom that can be caused by a variety of conditions, including fluid volume excess, especially in the case of pulmonary edema. It is not a direct indicator of fluid volume deficit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. PaCO2 48 mm Hg (35 to 45 mm Hg): In COPD, the body may have difficulty exhaling carbon dioxide, leading to elevated PaCO2 levels. A PaCO2 of 48 mm Hg indicates hypercapnia, especially in advanced stages where respiratory function is impaired.
B. HCO3- 25 mEq/L (21 to 28 mEq/L): HCO3- (bicarbonate) is within the normal range in the acute phase of COPD exacerbation. However, in chronic cases of COPD, bicarbonate levels may increase as the kidneys compensate for respiratory acidosis over time.
C. PaO2 85 mm Hg (80 to 100 mm Hg): A PaO2 of 85 mm Hg is within the normal range, but in clients with COPD, oxygen levels are often lower due to impaired gas exchange. It is common to see PaO2 values closer to or below 60 mm Hg in individuals with COPD.
D. pH 7.38 (7.35 to 7.45): A pH of 7.38 is normal and does not indicate acid-base imbalance. COPD clients often have a tendency towards respiratory acidosis, which may lower the pH, especially during exacerbations, but this value is not concerning for an acute problem.
Correct Answer is B
Explanation
Rationale:
A. Pitting edema: Pitting edema typically indicates fluid volume excess, not deficit. It occurs when there is an accumulation of fluid in the interstitial spaces, causing swelling that leaves an indentation when pressed.
B. Skin tenting: Skin tenting is a common sign of fluid volume deficit, particularly dehydration. It occurs when the skin loses elasticity due to a lack of adequate hydration, causing the skin to remain "tented" when pinched.
C. Elevated blood pressure: Elevated blood pressure is more commonly associated with fluid volume excess, not deficit. Increased fluid volume can lead to higher blood pressure due to greater circulating volume and increased vascular resistance.
D. Dyspnea: Dyspnea, or difficulty breathing, is a symptom that can be caused by a variety of conditions, including fluid volume excess, especially in the case of pulmonary edema. It is not a direct indicator of fluid volume deficit.
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