Which of the following signs are commonly associated with fluid volume deficit (hypovolemia)? (Select All that Apply.)

Orthostatic hypotension

Bradycardia

Decreased skin turgor

Weight gain

Pulmonary edema

Answer and Explanation

Correct Answer : A,C

A. Orthostatic hypotension is a common sign of hypovolemia, as the lack of fluid volume can lead to a drop in blood pressure when changing positions.
B. Bradycardia is not typically associated with fluid volume deficit; tachycardia is more common as the body tries to compensate for low blood volume.
C. Decreased skin turgor is a classic sign of dehydration and fluid volume deficit, indicating reduced skin elasticity.
D. Weight gain is associated with fluid volume overload, not deficit.
E. Pulmonary edema is related to fluid volume overload or congestive heart failure, not hypovolemia.

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Correct Answer is ["D","E","F","G"]

Explanation

D. Measure lactate level: Elevated lactate levels are a strong indicator of sepsis and can help guide treatment.

E. Administer broad-spectrum antibiotics: Prompt administration of antibiotics is crucial to combat the infection.

F. Rapidly administer 30 mL/kg of normal saline: Aggressive fluid resuscitation is necessary to improve blood pressure and tissue perfusion.

G. Obtain blood cultures: Blood cultures can help identify the specific organism causing the infection and guide antibiotic therapy.

Other interventions that may be considered, but not necessarily within the first hour, include:

A. Obtain a urine specimen: This can help identify a urinary tract infection as a potential source of sepsis.

B. Insert a nasogastric tube: This may be necessary if the client is unable to tolerate oral intake or requires gastric decompression.

C. Type and cross-match for 2 units of packed RBCs: This may be necessary if the client develops significant anemia or requires blood transfusion.

A. Client reports decreased groin pain of 3 on a 1 to 10 scale. B. The client tolerates a second dose of medication with no greater than 1+ peripheral edema. C. Respirations are unlabored. D. The client's blood pressure when arising from resting position is at premedication levels.

Correct Answer is C

Explanation

A. Decreased groin pain is not an indicator of therapeutic response specific to the effects of epinephrine in treating angioedema.
B. While tolerating a second dose of medication with minimal peripheral edema is positive, it does not directly reflect the immediate therapeutic effects of epinephrine.
C. Unlabored respirations indicate improved airway patency and reduced bronchoconstriction, which are key therapeutic outcomes of epinephrine administration in angioedema.
D. Blood pressure returning to premedication levels is beneficial but is not the most immediate indicator of epinephrine's therapeutic effect in managing angioedema.

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Which of the following signs are commonly associated with fluid volume deficit (hypovolemia)? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED) Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["D","E","F","G"]

Explanation

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

Correct Answer is C

Explanation

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