A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which finding indicates hypovolemia?

Distended neck veins

Rapid pulse rate

Urine output 45 mL/hr

Decreased respiratory rate

Answer and Explanation

The Correct Answer is B

Rationale:
A. Distended neck veins: Distended neck veins are typically associated with fluid volume excess, such as in heart failure or hypervolemia. In hypovolemia, the central venous pressure is low, often resulting in flat or collapsed neck veins due to the decreased circulating blood volume and reduced venous return.

B. Rapid pulse rate: Tachycardia is a key early sign of hypovolemia, as the heart attempts to compensate for decreased blood volume by increasing the heart rate to maintain adequate cardiac output. This compensatory mechanism helps preserve perfusion to vital organs during volume loss.

C. Urine output 45 mL/hr: A urine output of 45 mL/hr is considered adequate and within the normal range for an adult. In hypovolemia, renal perfusion typically decreases, often leading to oliguria (urine output less than 30 mL/hr), which would be a more specific indicator of fluid deficit.

D. Decreased respiratory rate: Hypovolemia generally triggers an increase in respiratory rate (tachypnea) as a compensatory response to improve oxygen delivery and perfusion. A decreased respiratory rate would be unusual and not characteristic of a volume-depleted state.

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Correct Answer is D

Explanation

Rationale:
A. Decreased calcium levels: Hypocalcemia may cause neuromuscular symptoms such as tetany or tingling but is not associated with exophthalmos (protruding eyes). Calcium imbalance does not typically cause changes in eye appearance.

B. Decreased somatotropin levels: Somatotropin (growth hormone) deficiency may lead to growth delay or reduced muscle mass, but it is not associated with changes in orbital appearance. Protruding eyes are unrelated to growth hormone levels.

C. Increased glucose levels: Elevated glucose is characteristic of diabetes mellitus and may lead to complications like neuropathy or retinopathy, but it does not cause eye protrusion.

D. Increased T4 levels: Elevated thyroxine (T4) is seen in hyperthyroidism, particularly in Graves' disease, which is strongly associated with exophthalmos. The protrusion results from inflammation and edema of orbital tissues, a hallmark of this thyroid disorder.

A. Client reports chest pain as 4 on a scale of 0 to 10 B. Client reports fatigue over the last several months C. Client reports intermittent epigastric discomfort upon exertion D. Client reports experiencing occasional nausea and heart palpitations E. History of smoking 1 pack per day for the past 30 years F. Past medical history of type 2 diabetes mellitus, systemic lupus erythematosus, hypertension, and hyperlipidemia G. Father died at age 50 with coronary artery disease

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Rationale:

Client reports chest pain as 4 on a scale of 0 to 10: Chest pain, even when moderate, is a red flag symptom for possible myocardial ischemia, especially in a high-risk client. Prompt evaluation is essential to rule out unstable angina or early myocardial infarction.
Client reports fatigue over the last several months: Chronic fatigue may be an early and often overlooked symptom of cardiovascular disease in women. In the context of other cardiac risk factors, this requires further cardiac workup.
Client reports intermittent epigastric discomfort upon exertion: Epigastric discomfort on exertion may reflect angina equivalents, especially in women and diabetic patients. It may indicate myocardial ischemia and requires immediate attention.
Client reports experiencing occasional nausea and heart palpitations: Nausea and palpitations may be atypical symptoms of cardiac ischemia or arrhythmias. These signs are concerning when paired with chest discomfort and cardiovascular history.
History of smoking 1 pack per day for the past 30 years: Smoking is a major modifiable risk factor for coronary artery disease. Long-term tobacco use contributes to endothelial dysfunction and increases the risk of acute cardiac events.
Past medical history of type 2 diabetes mellitus, systemic lupus erythematosus, hypertension, and hyperlipidemia: This cluster of comorbidities places the client at extremely high risk for cardiovascular complications. Each condition independently contributes to atherosclerosis and cardiac event risk.
Father died at age 50 with coronary artery disease:A strong family history of premature CAD significantly elevates this client’s cardiac risk. It intensifies the concern for hereditary predisposition to cardiovascular events.

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A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which finding indicates hypovolemia?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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