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. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk.

B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution.

C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma.

D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.

A. "Use salt substitutes to reduce your sodium intake." B. "Increase your fluid intake to 1,000 mL a day." C. "Include phosphorus-rich foods in your diet." D. "Avoid food products that contain trans-fats."

Correct Answer is D

Explanation

Rationale:
A. "Use salt substitutes to reduce your sodium intake.": Salt substitutes often contain potassium, which can accumulate to dangerous levels in clients with chronic kidney disease. Therefore, they should be avoided rather than recommended.

B. "Increase your fluid intake to 1,000 mL a day.": Clients on hemodialysis typically require fluid restrictions, not increases, to prevent fluid overload between dialysis sessions. Fluid allowances are individualized based on urine output and clinical status.

C. "Include phosphorus-rich foods in your diet.": Phosphorus levels tend to rise in clients with kidney failure, contributing to bone disease. These clients are advised to avoid phosphorus-rich foods like dairy, nuts, and cola beverages.

D. "Avoid food products that contain trans-fats.": Clients with chronic kidney disease are at increased risk for cardiovascular disease. Avoiding trans-fats, which raise LDL cholesterol and promote inflammation, supports heart health and is an appropriate dietary recommendation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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