A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
Loss of skin turgor
Weight gain
Hypotension
Bradycardia
The Correct Answer is B
Rationale:
A. Loss of skin turgor: Loss of skin turgor is a sign of dehydration, not hypervolemia. Hypervolemia typically results in fluid retention, leading to other symptoms such as weight gain.
B. Weight gain: Weight gain is a common sign of hypervolemia due to the accumulation of excess fluid in the body. It is often one of the first indicators of fluid overload.
C. Hypotension: Hypotension is more commonly associated with hypovolemia (fluid deficit) rather than hypervolemia. In hypervolemia, blood pressure is more likely to increase due to the excess fluid volume.
D. Bradycardia: Bradycardia is not typically associated with hypervolemia. Hypervolemia can lead to tachycardia (increased heart rate) as the body tries to compensate for the excess fluid volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Dyspnea at rest: Dyspnea at rest is a sign of advanced COPD, indicating that the client is experiencing significant respiratory difficulty. Pulmonary rehabilitation can help improve exercise tolerance and breathing, making this an appropriate reason for referral.
B. Pursed-lip breathing: Pursed-lip breathing is a technique often used by clients with COPD to help manage shortness of breath. It is not an indication for pulmonary rehabilitation, but rather a self-management strategy.
C. Clubbing of the fingers: Clubbing of the fingers can be a sign of chronic hypoxia and is commonly seen in advanced COPD. However, it does not directly indicate the need for pulmonary rehabilitation, although the condition may benefit from comprehensive care.
D. SPO2 90%: A SpO2 of 90% is low but not necessarily an indication for referral to pulmonary rehabilitation. It is important to monitor oxygen levels, but this alone does not trigger the need for rehabilitation.
Correct Answer is B
Explanation
Rationale:
A. "Drink a glass of milk with each meal." While milk can be a good source of calcium and protein, it may increase mucus production, which can be uncomfortable for clients with COPD or increase the work of breathing.
B. "Plan to include high-protein foods in each of your meals. "High-protein foods are essential for clients with COPD, as they help maintain muscle mass, support immune function, and prevent weight loss. These benefits are important for COPD patients, who may experience increased energy expenditure due to labored breathing.
C. "Increase your intake of vegetables such as broccoli and brussels sprouts." While vegetables are important, certain cruciferous vegetables like broccoli and brussels sprouts can cause gas and bloating, which can lead to discomfort for clients with COPD.
D. "Consume three large meals throughout the day." Clients with COPD may have difficulty consuming large meals due to breathlessness or early satiety. It is better to recommend smaller, more frequent meals to ensure adequate caloric intake.
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