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. Place a pillow between the client's legs: Placing a pillow between the client's legs is essential to maintain hip abduction and prevent dislocation. This keeps the new hip in proper alignment and reduces the risk of complications like dislocation.
B. Encourage the client to use an incentive spirometer every 4 hr: Using the spirometer every 4 hours is insufficient. The client should use it every 1-2 hours while awake to prevent atelectasis and promote deep breathing, especially after surgery.
C. Maintain the client on bed rest for 12 hr: Strict bed rest for 12 hours is not needed. Early mobilization helps prevent DVT and improve circulation, though activity should be limited to avoid stress on the surgical site.
D. Administer a topical antibiotic to the client's incision: Topical antibiotics are usually not given unless specifically ordered. Wound care after hip arthroplasty generally involves sterile dressings and monitoring for infection. Antibiotics if needed are administered systemically.
Correct Answer is C
Explanation
Rationale:
A. Increased heart rate: Increased heart rate can be a general sign of infection or discomfort, but it is not the earliest indication of peritonitis in peritoneal dialysis. Other symptoms like cloudy effluent typically present earlier.
B. Generalized abdominal pain: While abdominal pain can be a sign of peritonitis, it typically appears after other signs like cloudy effluent, so it is not usually the earliest indicator.
C. Cloudy effluent: Cloudy effluent is the earliest and most indicative sign of peritonitis in peritoneal dialysis. This is due to the presence of white blood cells and bacteria in the peritoneal fluid, which is a hallmark of infection.
D. Fever: Fever is a later symptom of peritonitis. It typically occurs after the infection has progressed and is not the earliest sign to monitor for in the context of peritoneal dialysis.
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