A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?
Decreased hematocrit
Decreased specific gravity of urine
Increased skin turgor
Increased pulse rate
The Correct Answer is D
A. Decreased hematocrit may be seen in fluid volume excess, not deficit.
B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.
D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
B) Placing weight on the axillae, or underarms, can cause nerve damage due to the pressure on the radial nerve located there; therefore, this is not a safe practice.
C) When descending stairs, the affected leg should be moved first, followed by the crutches and then the unaffected leg, to maintain balance and safety. Therefore, moving the unaffected leg onto a step first is not the safest option.
D) Having slightly flexed elbows allows for proper distribution of weight and helps in maintaining balance while ambulating with crutches, making it the correct and safe method.
Correct Answer is C
Explanation
A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.
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