A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
BUN 18 mg/dL.
A thready pulse.
Hemoglobin 15 g/dL.
Prominent neck veins.
The Correct Answer is B
The correct answer is choice B: A thready pulse.
Choice A rationale:
BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.
Choice B rationale:
A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.
Choice C rationale:
Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.
Choice D rationale:
Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is D
Explanation
The correct answer is choiced. "Describe your concerns about sleeping to me.".
Choice A rationale:
While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.
Choice B rationale:
Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.
Choice C rationale:
Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.
Choice D rationale:
Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.
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