A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?
Decreased heart rate
Increased blood pressure
Weak pulse
Dyspnea
The Correct Answer is C
Choice A reason: Decreased heart rate is not a manifestation of hypovolemia. Hypovolemia is a condition where there is a decreased volume of blood in the body, which can result from blood loss, dehydration, or fluid shifts. Hypovolemia can cause the heart rate to increase, not decrease, as the body tries to compensate for the low blood pressure and maintain adequate perfusion.
Choice B reason: Increased blood pressure is not a manifestation of hypovolemia. Hypovolemia can cause the blood pressure to decrease, not increase, as the blood volume and cardiac output are reduced. The body may try to constrict the blood vessels to increase the blood pressure, but this is usually not enough to overcome the effects of hypovolemia.
Choice C reason: Weak pulse is a manifestation of hypovolemia. Hypovolemia can cause the pulse to become weak, thready, or difficult to palpate, as the blood flow and pressure are diminished. The pulse may also become irregular or rapid, as the heart tries to pump faster and harder to deliver oxygen to the tissues.
Choice D reason: Dyspnea is not a specific manifestation of hypovolemia. Dyspnea is a term for difficulty breathing, which can have many causes, such as asthma, pneumonia, or pulmonary edema. Hypovolemia can cause dyspnea if it leads to shock, which is a life-threatening condition where the organs and tissues are not receiving enough oxygen. However, dyspnea alone is not enough to indicate hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not a correct result that the nurse should anticipate. RBC stands for red blood cells, which carry oxygen and carbon dioxide in the blood. The normal range for RBC is 4-5.5 /mm^3^, so a value of 4.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice B reason: This is a correct result that the nurse should anticipate. WBC stands for white blood cells, which fight infections and inflammation in the body. The normal range for WBC is 5-10 /mm^3^, so a value of 17 /mm^3^ is above the normal range and indicates leukocytosis, which is an increase in the number of white blood cells. Leukocytosis can be caused by acute appendicitis, as the body tries to fight the infection and inflammation in the appendix.
Choice C reason: This is not a correct result that the nurse should anticipate. Neutrophils are a type of white blood cell that are the first to respond to bacterial infections. The normal range for neutrophils is 3-5.8 /mm^3^, so a value of 3.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice D reason: This is not a correct result that the nurse should anticipate. Lymphocytes are a type of white blood cell that are involved in the immune response and the production of antibodies. The normal range for lymphocytes is 1-4 /mm^3^, so a value of 3 /mm^3^ is within the normal range and does not indicate any abnormality.
Correct Answer is D
Explanation
Choice A reason: A client who has a urine specific gravity of 1.010 is not dehydrated. Urine specific gravity is a measure of the concentration of solutes in the urine. A normal range is 1.005-1.030, which means that the urine is neither too dilute nor too concentrated. A high urine specific gravity (>1.030) indicates dehydration, as the urine becomes more concentrated due to fluid loss. A low urine specific gravity (<1.005) indicates overhydration, as the urine becomes more dilute due to fluid excess.
Choice B reason: A client who has a hematocrit of 42% is not dehydrated. Hematocrit is the percentage of red blood cells in the blood. A normal range is 36-46% for women and 40-54% for men. A high hematocrit (>54% for men and >46% for women) indicates dehydration, as the blood becomes more viscous due to fluid loss. A low hematocrit (<40% for men and <36% for women) indicates overhydration, as the blood becomes more diluted due to fluid excess.
Choice C reason: A client who has a temperature of 39 °C may or may not be dehydrated. Temperature is a measure of the body's heat production and regulation. A normal range is 36.5-37.5 °C. A high temperature (>37.5 °C) indicates fever, which can be caused by various factors, such as infection, inflammation, or medication. Fever can also cause dehydration, as the body loses fluid through sweating and increased respiration. However, fever is not a specific sign of dehydration, as there may be other causes or contributing factors.
Choice D reason: A client who has a weight loss of 2.2 kg in 24 hr is dehydrated. Weight loss is a measure of the change in the body's mass over time. A normal range is 0.5-1 kg per week. A rapid weight loss (>1 kg per day) indicates dehydration, as the body loses fluid through various routes, such as urine, stool, sweat, or vomit. Weight loss is a sensitive and reliable sign of dehydration, as it reflects the amount of fluid loss.
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