A nurse is caring for a client who has fluid volume deficit and is receiving a continuous IV infusion. Which of the following findings indicates the treatment has been effective?
Oliguria
Elastic skin turgor
Tachycardia
Dry mucous membranes
The Correct Answer is B
A) Oliguria, or decreased urine output, is a sign of fluid volume deficit rather than an indication that the treatment has been effective. In a client with fluid volume deficit, the kidneys conserve water to maintain fluid balance, leading to decreased urine output.
B) Elastic skin turgor is a reliable indicator of hydration status. When a client's fluid volume deficit is improving, their skin turgor returns to normal. Elastic skin turgor means that the skin quickly returns to its normal position after being pinched and released, indicating adequate hydration.
C) Tachycardia, or an increased heart rate, is a compensatory mechanism that the body uses to maintain cardiac output in response to fluid volume deficit. While tachycardia may initially be present in a client with fluid volume deficit, it is not an indication that treatment has been effective.
D) Dry mucous membranes are a manifestation of dehydration and fluid volume deficit. Moist mucous membranes indicate hydration status, and their dryness suggests dehydration. Dry mucous membranes are not indicative of effective treatment for fluid volume deficit.
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Related Questions
Correct Answer is B
Explanation
A) Blueberry muffins are not typically recommended for a client with cholecystitis. They are likely to be high in fat, which can exacerbate symptoms such as pain and discomfort associated with cholecystitis. Foods high in fat can trigger gallbladder contractions, leading to pain and potentially worsening the condition.
B) Graham crackers are a suitable option for a client with cholecystitis. They are low in fat and gentle on the digestive system, making them less likely to exacerbate symptoms. Foods that are low in fat and easy to digest are often recommended for individuals with cholecystitis to minimize discomfort and reduce the risk of triggering symptoms.
C) 2% milk is not typically recommended for a client with cholecystitis. Dairy products, especially those with higher fat content like 2% milk, can stimulate gallbladder contractions and worsen symptoms in individuals with cholecystitis. Therefore, it is usually advised to opt for lower-fat or non-dairy alternatives.
D) Ground beef is not typically recommended for a client with cholecystitis. Beef is high in fat, which can exacerbate symptoms and trigger gallbladder contractions. Clients with cholecystitis are often advised to avoid or limit high-fat foods to reduce the risk of discomfort and complications.
Correct Answer is ["42"]
Explanation
The nurse should set the IV pump to deliver approximately 42 mL/hr.
Here's the calculation:
Total volume of infusion (mL): 1,000 mL
Infusion time (hours): 24 hours
Flow rate (mL/hr) = Total volume (mL) / Infusion time (hours)
Flow rate (mL/hr) = 1,000 mL / 24 hours = 41.6666667 mL/hr (round to nearest whole number as requested)
Therefore, the nurse should set the pump to deliver 42 mL/hr.
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