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 B
Explanation
Choice A Reason:
Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach.
Choice B Reason:
Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit.
Choice C Reason:
Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function.
Choice D Reason:
Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the entrance to the larynx and directing the food or liquid down the esophagus.
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.