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A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

A.

Dependent edema

B.

Distended neck veins

C.

Postural hypotension

D.

Bradycardia

Answer and Explanation

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

Explanation

Choice A reason:

Limiting the session to 1 hour is a practical approach when teaching older adults. Research indicates that older adults may have shorter attention spans and may become fatigued more quickly than younger individuals. Therefore, keeping the session to a manageable length ensures that the participants remain engaged and retain the information presented. Additionally, shorter sessions can help prevent cognitive overload, making it easier for older adults to absorb and process the material.

Choice B reason:

Providing an environment with minimal distractions is crucial for effective learning, especially for older adults. Distractions such as noise, poor lighting, and uncomfortable seating can hinder concentration and reduce the effectiveness of the educational program. By creating a calm and focused environment, the nurse can help older adults concentrate better on the material being taught. This approach aligns with best practices in adult education, which emphasize the importance of a conducive learning environment.

Choice C reason:

Presenting the information at a 10th-grade reading level is important to ensure that the material is accessible to all participants. Older adults may have varying levels of literacy and educational backgrounds, so using clear and straightforward language helps to ensure that everyone can understand the content. This approach also helps to avoid any potential feelings of frustration or inadequacy that might arise if the material is too complex. Simplifying the language used in educational materials is a widely recommended practice in health education.

Choice D reason:

Using brightly colored paper for written materials can enhance the learning experience for older adults. Bright colors can capture attention and make the materials more visually appealing. Additionally, older adults may have visual impairments, and using high-contrast colors can improve readability. This technique can help to ensure that the written materials are engaging and accessible, thereby enhancing the overall effectiveness of the educational program.


Correct Answer is C

Explanation

Choice A Reason

Preparing an incident report is an important step in documenting the oversight and ensuring that similar errors are prevented in the future. However, it is not the immediate priority when addressing the current situation. The primary focus should be on ensuring the client’s safety and the timely completion of the necessary preoperative procedures.

Choice B Reason

Canceling the client’s surgery is a drastic measure that should only be considered if there is no other way to ensure the client’s safety. Before taking such a step, the nurse should explore all other options to rectify the situation, such as notifying the operative team and the provider. This allows for a collaborative approach to determine the best course of action.

Choice C Reason

Notifying the operative team of the omission is the most appropriate action. This ensures that all relevant healthcare providers are aware of the situation and can take the necessary steps to address it. The operative team can then decide whether to proceed with the surgery as planned or to delay it until the type and crossmatch are completed. This collaborative approach prioritizes the client’s safety and ensures that all necessary precautions are taken.

Choice D Reason

Giving the client another blood consent form to sign is not directly related to addressing the overlooked prescription for a type and crossmatch. While obtaining informed consent is crucial, it does not resolve the immediate issue of ensuring that the client has the correct blood type and crossmatch completed before surgery. The focus should be on rectifying the oversight and ensuring that all preoperative requirements are met.