Exhibits
The client likely has
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
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.
Correct Answer is C
Explanation
A. Describing the procedure in detail can increase anxiety or focus the client on the pain rather than distracting them from it.
B. Asking the client to describe the pain could heighten their awareness of it, which is counterproductive to the goal of distraction.
C. Encouraging the client to reminisce about a favorite past family event is a distraction technique that shifts the client's focus away from the pain, helping to manage discomfort during the procedure.
D. Explaining alternative pain management strategies is useful but not a distraction technique; it does not provide immediate relief or shift the client's focus during the procedure.
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