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. This area is the lateral side of the the heel and is more commonly affected by arterial ulcers or pressure injuries. It is not the typical location for ulcers caused by venous insufficiency.

B. This area is the area on the tip of toes and is not a typical site for venous ulcers. Ulcers in this location are commonly arterial or diabetic ulcers.

C. This area is the area on the sole of the feet at the base of the big toe and is not a typical site for venous ulcers.
D. This area is the medial malleolus, just above the inner ankle, which is the most common site for venous ulcers. Chronic venous insufficiency leads to venous stasis and increased pressure in this region, causing skin breakdown and ulceration.

A. Administer oxygen B. Obtain prescription for amiodarone C. Place client in semiFowler's position D. Monitor blood pressure every 30 minutes E. Obtain prescription for a beta blocker F. Monitor for neurologic complications

Correct Answer is ["A","C","E","F"]

Explanation

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.

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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

A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?

Correct Answer is D

Explanation

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Correct Answer is ["A","C","E","F"]

Explanation

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