A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
Bradycardia
Oliguria
Peripheral edema
Hypotension
The Correct Answer is C
A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.
B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.
C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.
D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply Neosporin to avoid infection:
This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.
B. Apply elbow immobilizers when not being held:
This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.
C. Suction secretions away from the suture line:
This is the recommended choice. Suctioning helps maintain a clear airway and prevents secretions from affecting the surgical site. It's a crucial step in the immediate postoperative period.
D. Feed increased amounts of formula to prevent weight loss:
While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.
Correct Answer is D
Explanation
A. Intact skin with localized erythema:
Explanation: This description is more consistent with a stage 1 pressure injury, where there is non-blanchable erythema.
B. Full thickness skin loss with visible bone:
Explanation: This description is more consistent with a stage 4 pressure injury, which involves extensive tissue loss, including exposure of bone.
C. Full thickness skin loss with visible adipose tissue:
Explanation: This finding is characteristic of a stage 3 pressure injury, where the loss of tissue extends down to the subcutaneous layer.
D. Partial-thickness skin loss with red tissue in the wound bed:
Explanation: This description is consistent with a stage 2 pressure injury, where there is partial-thickness skin loss involving the epidermis and possibly the dermis, forming a shallow open ulcer with a red-pink wound bed.
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