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","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.
Correct Answer is D
Explanation
Choice A Reason:
Logrolling is a technique used to turn a patient while maintaining the alignment of the spine. It is particularly important for patients with spinal injuries or those who have undergone spinal surgery. While preventing friction is a benefit, the primary purpose of logrolling is to maintain spinal alignment and prevent further injury.
Choice B Reason:
Keeping the arms at the sides while logrolling is not a standard recommendation. In fact, it is often suggested that patients cross their arms over their chest to minimize lateral spinal displacement during the roll. This helps in maintaining the alignment of the spine and preventing any twisting or bending.
Choice C Reason:
The head of the bed should be flat during logrolling to ensure proper spinal alignment. Elevating the head of the bed can cause misalignment and increase the risk of injury. The bed should be positioned flat and at a comfortable working height for the caregivers performing the logroll.
Choice D Reason:
Logrolling is specifically designed to keep the spine in alignment. This technique involves turning the patient in one smooth motion without twisting or bending the body. It is crucial for patients with spinal injuries to prevent further damage and ensure safe repositioning.
