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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Correct Answer is A
Explanation
Choice A reason:
“Why do you feel upset about this?” is a response that opens up a dialogue and allows the nurse to express their feelings and concerns. It shows that the nurse manager is interested in understanding the nurse’s perspective and is willing to listen. This approach can help identify any underlying issues and work towards a resolution. It is important for managers to create an environment where employees feel heard and supported.
Choice B reason:
“You should be working harder.” is a dismissive response that does not address the nurse’s concerns. It can make the nurse feel undervalued and unappreciated, leading to decreased morale and job satisfaction. This response does not foster a supportive work environment and can exacerbate feelings of frustration and resentment. Effective management involves acknowledging employees’ efforts and addressing their concerns constructively.
Choice C reason:
“I will reprimand your team members.” is a response that may seem supportive at first glance, but it can create a negative work environment. Reprimanding team members without understanding the full context can lead to resentment and conflict within the team. It is important for managers to address performance issues in a fair and constructive manner, focusing on solutions rather than punishment.
Choice D reason:
“You must feel frustrated.” is an empathetic response that acknowledges the nurse’s feelings. It shows that the nurse manager understands the nurse’s frustration and is willing to listen. This response can help build trust and rapport between the nurse and the manager, creating a more positive and supportive work environment. Empathy is a key component of effective leadership and can help address and resolve workplace issues.
Correct Answer is A
Explanation
Choice A Reason
Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively.
Choice B Reason
Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface.
Choice C Reason
Holding the dropper 3 cm (1.2 in) away from the client’s eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination.
Choice D Reason
Massaging the client’s eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.