Exhibits
Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.
Which three of the following client findings indicate that the client may still have a fluid volume deficit?
Heart rate 99 beats/minute
Dark, yellow urine
Urinated 30 mL
Temperature 101° F (38.3° C)
Correct Answer : A,B,C
A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Measles Mumps Rubella (MMR) vaccine is typically administered at 12-15 months of age, not at 2 months. It is part of the recommended immunization schedule but is not given during the 2-month visit.
B. Varicella vaccine is usually given at 12-15 months of age. It is essential for preventing chickenpox but is not included in the 2-month immunization schedule.
C. Hepatitis A vaccine is recommended starting at 12 months of age. It is not part of the immunizations administered at 2 months.
D. Hepatitis B vaccine is part of the routine immunization schedule for infants and is given at birth, 1-2 months, and 6-18 months. At the 2-month visit, it is appropriate to administer the second dose of the Hepatitis B vaccine if it was not given at 1 month.
Correct Answer is ["B","D","E"]
Explanation
A. Bacterial conjunctivitis is not a reportable infectious disease according to the CDC. While it is a common condition, it does not fall under the mandatory reporting requirements for public health.
B. Diphtheria is a reportable disease because it is a severe bacterial infection that can lead to outbreaks and severe health consequences. Reporting helps track and control the spread of this potentially life-threatening disease.
C. Pediculosis (head lice) is not a reportable disease by the CDC. It is a common parasitic infestation but does not require mandatory reporting for public health surveillance.
D. Anthrax is a reportable disease due to its potential for severe illness and its use as a bioterrorism agent. Reporting anthrax is crucial for monitoring and managing outbreaks and potential public health threats.
E. Tuberculosis is a reportable disease because it is a serious infectious disease that can spread in communities and requires public health measures to manage and prevent outbreaks.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.