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 A
Explanation
Choice A: I will walk three times per week.
Walking is a weight-bearing exercise, which is crucial for maintaining bone density and reducing the risk of osteoporosis. Regular physical activity, especially weight-bearing exercises like walking, helps stimulate bone formation and slows down bone loss. The National Osteoporosis Foundation recommends at least 30 minutes of weight-bearing exercise on most days of the week to help prevent osteoporosis.
Choice B: I will avoid exposure to the sun.
Avoiding sun exposure is not advisable for reducing the risk of osteoporosis. Sunlight is a natural source of vitamin D, which is essential for calcium absorption and bone health. While excessive sun exposure can be harmful, moderate exposure helps the body produce sufficient vitamin D. Therefore, avoiding sun exposure entirely can lead to vitamin D deficiency, increasing the risk of osteoporosis.
Choice C: I will take 250 milligrams of calcium once per day.
The recommended daily intake of calcium for older adults is significantly higher than 250 milligrams. For adults aged 51 and older, the National Institutes of Health recommends 1,200 milligrams of calcium per day. Adequate calcium intake is vital for maintaining bone health and preventing osteoporosis. Therefore, taking only 250 milligrams of calcium per day is insufficient to meet the body’s needs.
Choice D: I will decrease my intake of dairy products.
Dairy products are a primary source of calcium, which is essential for bone health. Reducing the intake of dairy products can lead to inadequate calcium intake, increasing the risk of osteoporosis. Instead, older adults should ensure they consume enough dairy or other calcium-rich foods to meet their daily calcium requirements.
Correct Answer is B
Explanation
Choice A reason:
Lowering the head of the client’s bed to 15 degrees can help facilitate the drainage of the NG tube. This position uses gravity to assist in the movement of gastric contents through the tube. However, it is not the most effective method to address the issue of the NG tube not draining. This action might be more appropriate for other clinical scenarios, such as preventing aspiration, but it is not the primary intervention for a non-draining NG tube.
Choice B reason:
Injecting 10 mL of air into the vent lumen is a common technique used to clear an obstruction in the NG tube. This action can help dislodge any blockages that may be preventing the tube from draining properly. By injecting air, the nurse can ensure that the tube is patent and functioning correctly. This method is often recommended in clinical guidelines for managing NG tube blockages.
Choice C reason:
Placing the NG tube to high suction is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. High suction can create excessive negative pressure, which can harm the delicate tissues of the stomach lining. Therefore, this action is not appropriate for managing a non-draining NG tube and should be avoided.
Choice D reason:
Connecting the air vent to the suction is incorrect and can lead to malfunction of the NG tube. The air vent, also known as the pigtail, is designed to allow air to enter the stomach and prevent the tube from adhering to the gastric mucosa. Connecting it to suction would negate its purpose and could cause the tube to become blocked or damaged. This action is not recommended in any clinical guidelines for NG tube management.
