A nurse is caring for a client who is receiving IV 0.9% sodium chloride for the treatment of hypovolemia. Which of the following findings should the nurse identify as an indication the treatment is effective?
Heart rate 104/min
2+ pitting edema in lower extremities
Blood pressure 124/74 mm Hg
Increased hematocrit
The Correct Answer is C
A. A heart rate of 104/min may indicate continued hypovolemia or a compensatory response to volume loss.
B. Pitting edema suggests fluid overload rather than effective treatment of hypovolemia.
C. A blood pressure of 124/74 mm Hg within or close to the normal range indicates improved volume status and effective treatment of hypovolemia.
D. Increased hematocrit suggests hemoconcentration due to volume loss rather than effective treatment.
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Related Questions
Correct Answer is D
Explanation
A. INR is not relevant to the effectiveness of filgrastim, which is used to stimulate WBC production.
B. BUN is related to kidney function, not the effectiveness of filgrastim.
C. Potassium level is not affected by filgrastim.
D. Filgrastim is given to increase WBC count, so monitoring the WBC count is necessary to evaluate its effectiveness.
Correct Answer is B
Explanation
A. Insulin glargine is a long-acting insulin and should not be taken additionally before exercise; adjustments are usually made with short-acting insulin.
B. Wearing reading glasses will help ensure that the client accurately measures the correct dose, which is essential for safe administration.
C. Insulin is typically injected subcutaneously in areas like the abdomen, thigh, or back of the arm, not the deltoid muscle.
D. Insulin glargine is usually administered once daily at the same time each day, not before each meal.
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