A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

Full bounding pulse

Cool extremities

Moist crackles in the lungs

Orthostatic hypotension

Flat neck veins

Answer and Explanation

Correct Answer : B,D,E

A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit.
B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit.
C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit.
D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume.
E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.

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Correct Answer is C

Explanation

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

Correct Answer is D

Explanation

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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