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:
A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.
Choice B reason:
A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.
Choice C reason:
A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.
Choice D reason:
A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.
Correct Answer is C
Explanation
Choice A: Have a padded tongue blade available at the client’s bedside.
Having a padded tongue blade available is not recommended for seizure management. Inserting any object into a patient’s mouth during a seizure can cause injury to the teeth, gums, or jaw1. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus on ensuring the patient’s safety by turning them on their side to maintain an open airway and prevent aspiration.
Choice B: Keep the four side rails down when the client is in bed.
Keeping the side rails down is not advisable for a client with a seizure disorder. To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls.
Choice C: Keep suction equipment available in the client’s room.
Keeping suction equipment available is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client’s airway, reducing the risk of aspiration and ensuring the client can breathe properly.
Choice D: Have wire cutters available at the client’s bedside.
Wire cutters are not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where the wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders4.