A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?
Dependent edema
Distended neck veins
Postural hypotension
Bradycardia
The Correct Answer is C
Choice A reason:
Dependent edema is not typically associated with extracellular fluid volume deficit. Edema usually occurs due to fluid overload or conditions that cause fluid retention, such as heart failure or kidney disease. In the case of extracellular fluid volume deficit, the body is losing more fluid than it is taking in, which would not result in edema. Instead, symptoms like dry skin, dry mucous membranes, and decreased skin turgor are more common.
Choice B reason:
Distended neck veins are also not a common finding in extracellular fluid volume deficit. Distended neck veins are usually seen in conditions where there is fluid overload or increased pressure in the venous system, such as heart failure or superior vena cava syndrome. In extracellular fluid volume deficit, the body is experiencing a reduction in fluid volume, which would not cause distended neck veins.
Choice C reason:
Postural hypotension, also known as orthostatic hypotension, is a common finding in extracellular fluid volume deficit. This condition occurs when there is a significant drop in blood pressure upon standing, leading to dizziness or lightheadedness. It is caused by the reduced blood volume, which decreases the amount of blood returning to the heart and subsequently lowers blood pressure.
Choice D reason:
Bradycardia, or a slow heart rate, is not typically associated with extracellular fluid volume deficit. In fact, the opposite is more likely to occur. Tachycardia, or a fast heart rate, is a common compensatory mechanism in response to fluid volume deficit as the body attempts to maintain adequate blood flow and pressure. Therefore, bradycardia would not be an expected finding in this scenario.
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View Related questions
Correct Answer is C
Explanation
Choice A Reason
Using sterile gloves to obtain the sputum specimen is important for maintaining sterility and preventing contamination. However, it is not the first priority action. The timing of the collection is more critical to ensure the accuracy and quality of the specimen.
Choice B Reason
Obtaining the sputum specimen after the client uses mouthwash is incorrect. Mouthwash can kill or alter the microorganisms present in the sputum, leading to inaccurate test results. The client should rinse their mouth with water instead to reduce contamination from oral secretions.
Choice C Reason
Collecting the sputum specimen in the morning is the most appropriate action. Sputum accumulates overnight, making it easier to collect a sufficient sample in the morning. This timing also ensures that the specimen is more concentrated and representative of the lower respiratory tract.
Choice D Reason
Placing the sputum specimen in a clean container is necessary, but it is not the first action to take. The container should be sterile to prevent contamination and ensure the accuracy of the test results. However, the timing of the collection is more critical to obtaining a quality specimen.
Correct Answer is D
Explanation
Choice A Reason:
Telling the client to ask their provider if they recommend traditional Chinese medicine (TCM) is a cautious approach, but it may not fully address the client’s interest in exploring alternative treatments. While it is important for the client to discuss their treatment options with their provider, the nurse can take a more proactive role by facilitating access to TCM practitioners.
Choice B Reason:
Suggesting that the client try the prescribed medication before choosing an alternative may come across as dismissive of the client’s preferences. It is important to respect the client’s autonomy and support their informed decision-making. Encouraging the client to explore TCM while also considering the prescribed medication can be a more balanced approach.
Choice C Reason:
Stating that the FDA regulates traditional Chinese medicine is inaccurate. The FDA does not regulate TCM in the same way it regulates conventional pharmaceuticals. TCM practices and products are subject to different regulatory standards, and it is important for the nurse to provide accurate information about the regulatory status of TCM.
Choice D Reason:
Offering to arrange a referral to a practitioner of traditional Chinese medicine is an appropriate and supportive response. This approach respects the client’s interest in TCM and facilitates access to qualified practitioners who can provide safe and effective care. It also ensures that the client receives comprehensive information about their treatment options.
