A nurse is monitoring a client who is admitted with severe hemorrhage from traumatic injury who is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Weight
Heart rate
Urine output
BP
The Correct Answer is B
A. Weight may fluctuate but is not a direct indication of immediate fluid resuscitation adequacy.
B. A decrease in heart rate is a sign of improved perfusion and stabilization, suggesting that fluid replacement is effective in compensating for blood loss.
C. Adequate fluid replacement is indicated by an increase, not a decrease, in urine output.
D. Blood pressure should stabilize or increase with fluid replacement, rather than decrease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Macrovascular angiopathy refers to damage in large and medium-sized vessels, which is associated with cerebrovascular, cardiovascular, and peripheral vascular disease in diabetic patients.
B. Diabetic nephropathy involves the kidneys, not the large or medium blood vessels.
C. Diabetic neuropathy affects nerves rather than blood vessels.
D. Microvascular angiopathy involves small vessels, typically affecting the eyes, kidneys, and nerves.
Correct Answer is B
Explanation
A. Instructing the UAP to obtain a blood glucose level could be useful, but the nurse should prioritize assessing the client directly.
B. Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.
C. Administering orange juice may be appropriate after confirming hypoglycemia, but an assessment should be performed first.
D. Administering dextrose is a severe intervention used when symptoms are extreme; assessment should occur first.
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