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 D
Explanation
Choice A reason:
“Use a size 20 French catheter for catheterization.” This statement is incorrect. Using a larger catheter size, such as 20 French, can increase the risk of trauma and infection. It is generally recommended to use the smallest catheter size possible to minimize the risk of catheter-associated urinary tract infections (CAUTIs) and other complications.
Choice B reason:
“Allow the drainage bag to fill completely before emptying.” This statement is incorrect. Allowing the drainage bag to fill completely can increase the risk of infection and cause backflow of urine into the bladder. It is recommended to empty the drainage bag when it is two-thirds full to prevent these issues.
Choice C reason:
“Disconnect the drainage tube if the catheter requires irrigation.” This statement is incorrect. Disconnecting the drainage tube can break the closed system and increase the risk of infection. If irrigation is necessary, it should be done using a closed system to maintain sterility and reduce the risk of CAUTIs.
Choice D reason:
“Keep the collection bag below bladder level.” This statement is correct. Keeping the collection bag below bladder level helps prevent backflow of urine into the bladder, which can reduce the risk of infection. This practice is a key component of preventing CAUTIs and is recommended in clinical guidelines.
Correct Answer is ["A","E"]
Explanation
Choice A Reason:
Cutting the opening of the pouch 1/8 inch larger than the stoma is crucial to ensure a proper fit and to prevent skin irritation. The stoma can change size, especially in the initial weeks post-surgery, so it is important to measure it regularly and adjust the pouch opening accordingly. This practice helps in maintaining a secure seal and protecting the skin around the stoma from exposure to waste.
Choice B Reason:
Placing a piece of gauze over the stoma while changing the pouch can help in absorbing any output and keeping the area clean during the change. However, this is more of a practical tip rather than a strict instruction for ostomy care. It is not essential for all patients and may vary based on individual preferences and needs.
Choice C Reason:
Expecting the stoma to turn a purple-blue color as it heals is incorrect. A healthy stoma should be pink or red and moist. A purple-blue color can indicate poor blood supply or other complications and should be reported to a healthcare provider immediately. Proper stoma care includes monitoring its color and seeking medical advice if any unusual changes occur.
Choice D Reason:
Using povidone-iodine to clean around the stoma is not recommended. The skin around the stoma should be cleaned with mild soap and water or just water. Povidone-iodine can be too harsh and may cause irritation or allergic reactions. It is important to use gentle cleaning methods to maintain skin integrity and prevent complications.
Choice E Reason:
Emptying the ostomy pouch when it becomes one-third full of contents is a standard practice to prevent leaks and maintain comfort. Overfilling the pouch can lead to detachment from the skin and potential skin irritation. Regular emptying helps in managing the ostomy effectively and maintaining hygiene.