The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

hypovolemic shock.

hemodilution.

excess fluid volume.

deficient fluid volume.

Answer and Explanation

The Correct Answer is C

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

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Correct Answer is C

Explanation

A. always has a religious connotation: This statement is incorrect. While spirituality can be intertwined with religion for many individuals, it does not always have a religious connotation. Spirituality encompasses a broader sense of connection to something greater than oneself, which may or may not be associated with organized religion.

B. is a narrower concept than religion: This statement is incorrect. Spirituality is often considered a broader concept than religion. While religion typically involves organized beliefs, rituals, and practices within a specific faith tradition, spirituality encompasses a wider range of experiences, beliefs, and practices that relate to the search for meaning, purpose, and connection to the transcendent.

C. does not necessarily include religion: This statement is correct. Spirituality can exist independently of religion. While religion often involves spirituality, spirituality can encompass a wide range of beliefs, experiences, and practices that may or may not be connected to organized religion. Individuals can experience spirituality through various means such as nature, relationships, art, meditation, and personal reflection, regardless of religious affiliation.

D. has been created by humans to define ethical conduct: This statement is incorrect. Spirituality is not solely created by humans to define ethical conduct. While ethical principles and values may be part of spiritual beliefs for many individuals, spirituality encompasses broader aspects of human experience, including the search for meaning, connection, and transcendence, which extend beyond ethical conduct.

A. Isotonic B. Hypotonic C. Hypertonic D. Colloid

Correct Answer is A

Explanation

A. Isotonic: Isotonic fluids have a similar osmolarity to extracellular fluid and are often used for volume replacement in clients with fluid volume deficits, such as those with gastroenteritis. Isotonic fluids help to expand intravascular volume without causing significant shifts in fluid and electrolyte balance.

B. Hypotonic: Hypotonic fluids have a lower osmolarity than extracellular fluid and are typically used to rehydrate cells in cases of cellular dehydration. While hypotonic fluids can replenish intracellular volume, they are not typically used as initial replacement fluids for clients with fluid volume deficits, especially if there is risk of exacerbating extracellular fluid deficit.

C. Hypertonic: Hypertonic fluids have a higher osmolarity than extracellular fluid and are often used to expand intravascular volume in specific situations, such as severe hyponatremia or hypovolemic shock. However, they are not typically used as initial replacement fluids for clients with gastroenteritis and fluid volume deficits.

D. Colloid: Colloids are solutions containing large molecules, such as albumin or starches, which remain within the vascular space and exert oncotic pressure to draw fluid into the intravascular compartment. While colloids may be used in some cases of severe volume deficit, they are not typically used as initial replacement fluids for clients with gastroenteritis.

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The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

Correct Answer is C

Explanation

The physician has ordered replacement fluids for a client who has a fluid volume deficit with a diagnosis of gastroenteritis. The nurse would expect the use of which type of fluids initially upon admission?

Correct Answer is A

Explanation

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