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 Reason:
Airborne precautions are necessary for clients with tuberculosis (TB) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections.
Choice C Reason:
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.
Correct Answer is B
Explanation
Choice A Reason:
Using extension cords to prevent overloading circuits is not a recommended safety practice. Extension cords can pose tripping hazards and may not be designed to handle the electrical load of multiple devices, which can lead to overheating and potential fire risks.
Choice B Reason:
Obtaining a raised toilet seat for the bathroom is a practical safety measure for older adults. It helps reduce the risk of falls by making it easier for individuals with limited mobility to sit down and stand up from the toilet. This modification can significantly enhance bathroom safety.
Choice C Reason:
Covering slippery stairs with an area rug is not advisable. Area rugs can slip and create additional hazards. Instead, using non-slip treads or securing the rug with non-slip backing is a safer alternative.
Choice D Reason:
Securing loose wires under carpeting is not recommended. This practice can create a fire hazard and make it difficult to access the wires if needed. It’s better to use cable management solutions that keep wires organized and out of the way without hiding them under carpeting.