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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Correct Answer is ["B","C","D"]
Explanation
Choice A Reason:
When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors.
Choice B Reason:
At the client’s bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the “three checks” process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors.
Choice C Reason:
Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the “three checks” and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen.
Choice D Reason:
While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the “three checks” and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection.
Choice E Reason:
When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.
Correct Answer is B
Explanation
Choice A Reason
Placing the client in a high-Fowler’s position during the assessment is not necessary for assessing the carotid arteries. While this position can be useful for other assessments, it is not specifically required for carotid artery evaluation. The client can be in a seated or supine position with the head slightly elevated.
Choice B Reason
Auscultating each carotid artery with the bell of the stethoscope is the most appropriate action. This technique allows the nurse to listen for bruits, which are abnormal sounds indicating turbulent blood flow due to partial obstruction or narrowing of the artery. Using the bell of the stethoscope is crucial because it is better suited for detecting low-pitched vascular sounds.
Choice C Reason
Palpating the carotid arteries simultaneously is not recommended. Doing so can significantly reduce blood flow to the brain, potentially causing dizziness or fainting. Instead, each carotid artery should be palpated individually to assess the amplitude and contour of the pulse without compromising circulation.
Choice D Reason
Massaging the carotid artery while assessing the client is inappropriate and potentially dangerous. Massaging the carotid artery can stimulate the carotid sinus, leading to a reflex drop in heart rate and blood pressure, which can cause syncope (fainting). This action should be avoided during assessment.
