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 D

Explanation

A. This gait involves both crutches advancing simultaneously followed by both legs.

B. This gait involves swinging both legs and crutches forward at the same time.

C. This gait involves alternating movement of each crutch and leg, providing more stability but may be difficult for a client with limited weight-bearing on one leg.
D. In this gait, the client advances both crutches and the affected leg simultaneously, followed by the unaffected leg.

A. Release the skin before withdrawing the needle. B. Insert at a 45° angle. C. Withdraw the needle quickly. D. Pull the skin laterally.

Correct Answer is D

Explanation

A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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