A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?

Fluid overload

Intracardiac shunt

Hypovolemia

Left ventricular failure

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because ﬂuid overload is a condition of excess ﬂuid volume in the body. A client who has ﬂuid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.

Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood ﬂow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.

Choice C Reason: This is correct because hypovolemia is a condition of low ﬂuid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.

Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because hypervolemia is a condition of excess ﬂuid volume in the body. A client who has an extensive burn injury is more likely to have hypovolemia, which is a condition of low ﬂuid volume, due to ﬂuid loss from the damaged skin and capillaries.

Choice B Reason: This is incorrect because metabolic alkalosis is a condition of high blood pH and high bicarbonate level. A client who has an extensive burn injury is more likely to have metabolic acidosis, which is a condition of low blood pH and low bicarbonate level, due to increased production of lactic acid and ketones from tissue hypoxia and breakdown.

Choice C Reason: This is correct because low hemoglobin is a common laboratory finding in a client who has an extensive burn injury. Hemoglobin is the protein in red blood cells that carries oxygen. A client who has an extensive burn injury may have low hemoglobin due to hemolysis, which is the destruction of red blood cells, or hemorrhage, which is the loss of blood.

Choice D Reason: This is incorrect because hyperkalemia is a condition of high blood potassium level. A client who has an extensive burn injury may have hyperkalemia in the early phase of injury, due to cell damage and potassium release, but it is usually transient and followed by hypokalemia, which is a condition of low blood potassium level, due to ﬂuid loss and potassium depletion.

A. The client is in deep coma. B. The client needs total nursing care. C. The client is alert and oriented. D. The client is responding to verbal stimuli. E. The client is responding to verbal stimuli.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the client is not in deep coma, as the Glasgow Coma Scale (GCS) score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client needs total nursing care, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only open his eyes to pain, make incomprehensible sounds, and have abnormal ﬂexion to pain.

Choice C Reason: This is incorrect because the client is not alert and oriented, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may not be able to follow commands, answer questions, or recognize people or places.

Choice D Reason: This is incorrect because the client is not responding to verbal stimuli, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only respond to painful stimuli, such as pinching or squeezing.

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A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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