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A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)

Amber/dark colored urine

Weak, thready pulse

Distended neck veins

Bradycardia

Decreased capillary refill

Answer and Explanation

Correct Answer : A,B,E

A. Amber or dark-colored urine is a sign of dehydration and indicates a decrease in fluid volume.

B. A weak, thready pulse is often seen in clients with hypovolemia due to reduced circulating blood volume.

C. Distended neck veins are a sign of fluid overload, not hypovolemia.

D. Bradycardia is typically not associated with hypovolemia; tachycardia is more common.

E. Decreased capillary refill is indicative of reduced perfusion, a symptom of hypovolemia.

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Correct Answer is ["B","C","D"]

Explanation

A. Pale yellow urine would not be expected, as dehydration often leads to concentrated, dark urine.

B. Flat neck veins are a sign of dehydration and decreased fluid volume.

C. Hypotension is expected with dehydration due to a drop in circulating blood volume.

D. Poor skin turgor is a common indicator of dehydration as the skin loses elasticity.

E. Bradycardia is not expected; rather, tachycardia is more common in dehydration as the body tries to compensate for fluid loss.

Correct Answer is "{\"xRanges\":[89.96875,99.96875],\"yRanges\":[232.87109375,242.87109375]}"

Explanation

The posterior tibial pulse is typically palpated just behind the medial malleolus, which is the bony prominence on the inner side of the ankle. To locate this pulse, one should place their fingers in the groove between the medial malleolus and the Achilles tendon.

While checking the client's medication administration record, it was determined the client

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A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)

Nursing Test Bank

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Correct Answer is ["B","C","D"]

Explanation

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[89.96875,99.96875],\"yRanges\":[232.87109375,242.87109375]}"

Explanation

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