A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Distended neck veins

Postural hypotension

Dependent edema

Bradycardia

Answer and Explanation

The Correct Answer is B

A.   Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B.   In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C.   Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D.   Bradycardia is not typically associated with extracellular fluid volume deficit.

Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.

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Correct Answer is A

Explanation

A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

A. Hold the dropper 3 cm (1.2 in) away from the client's eye. B. Massage the client's eyelids for 20 seconds after instillation. C. Wait 5 min between the administration of each medication. D. Ask the client to close their eyes tightly after instilling each medication.

Correct Answer is C

Explanation

A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Nursing Test Bank

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