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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A) Wear sterile gloves during a feeding: While hand hygiene is essential when handling enteral feeding equipment, wearing sterile gloves for administering intermittent enteral feedings is not typically necessary. Standard precautions, including handwashing and using clean gloves, are sufficient to prevent infection.
B) Flush the tubing with 15 mL of water after each feeding: Flushing the tubing with water after each feeding helps prevent clogging and ensures that the full dose of the feeding is delivered to the client. It also helps maintain tube patency and reduces the risk of bacterial growth in the tubing.
C) Position the client upright prior to a feeding: Positioning the client upright, typically at a 30 to 45-degree angle, helps prevent aspiration during enteral feedings. This position promotes proper flow of the feeding into the stomach, reduces the risk of reflux, and facilitates digestion. It also helps ensure that the feeding reaches the intended destination and minimizes the risk of complications such as aspiration pneumonia.
D) Chill the feeding prior to administering: Chilling the feeding is not a standard practice for administering intermittent enteral feedings. In fact, administering cold feedings may cause discomfort and gastrointestinal upset in some clients. It is generally recommended to administer enteral feedings at room temperature or slightly warmed to body temperature to enhance tolerance and absorption.
Correct Answer is D
Explanation
A) Wipe dentures before storing them in a dry container at night: This instruction is correct. Dentures should be cleaned before storage to remove any debris or food particles. Storing dentures in a dry container overnight helps prevent bacterial growth and maintains their shape.
B) Floss dentures as part of daily cleaning: Flossing dentures is not typically necessary, as they are not natural teeth with interdental spaces. Instead, dentures should be cleaned using a denture brush or soft-bristled toothbrush to remove plaque and debris.
C) Use a washcloth to clean the denture surfaces: While a washcloth can be used to clean the denture surfaces, it may not be as effective as using a denture brush or soft-bristled toothbrush specifically designed for cleaning dentures. These tools are better at removing plaque and debris without damaging the denture material.
D) Wrap gloved fingers with gauze to remove dentures: This instruction is incorrect. When removing dentures, it's essential to use both hands to grasp them firmly and gently rock them back and forth to release the seal. Using gloved fingers wrapped with gauze may not provide enough grip and could potentially damage the dentures or injure the gums.
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