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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: While volunteering at a local food pantry can be a meaningful activity, it is not the priority when considering Maslow's hierarchy of needs. Physiological needs, such as nutrition and exercise, take precedence.
B: Correct. Attending an exercise program addresses the client's physiological needs (specifically the need for physical activity and health) and takes priority over other options in this context.
C: Finding an enjoyable hobby addresses the client's need for self-fulfillment and self-esteem, which comes at a higher level in Maslow's hierarchy. It is not the immediate priority during discharge planning.
D: Supporting environmental conservation aligns with self-actualization, which is a higher-level need in Maslow's hierarchy. It is not the priority during discharge planning.
Correct Answer is ["1820"]
Explanation
1. IV fluids:
- 150 mL/hr * 8 hr = 1200 mL
2. Juice:
- 4 oz * 30 mL/oz = 120 mL
3. Water:
- 0.5 L * 1000 mL/L = 500 mL
Total intake:
- 1200 mL + 120 mL + 500 mL = 1820 mL
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