A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has
fluid volume deficit. Which of the following changes
... [Show More] should the nurse identify as an
indication that the treatment was successful?
Increase in hematocrit
increase in respiratory rate
Decrease in heart rate
Decrease in capillary refill time - Correct Answer:
Decrease in heart rate
Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate
should return to the expected range.
Incorrect Answers:
Increase in hematocrit:
Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular
fluid. With correction of the imbalance, the hematocrit level should decrease.
increase in respiratory rate
Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance,
the respiratory rate should return to the expected range.
Decrease in capillary refill time
Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill
time should return to the expected range.
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility.
The client's family questions the nurse about the reasons for the transfer. Which of the
following responses made by the nurse is appropriate?
"The transfer of your family member is being done because the provider knows what's best."
"Would you like it if we discussed the transfer with your family member?"
"Why are you so concerned about this transfer?"
"I know how you feel. My parent had to be transferred to a long-term care facility." - Correct
Answer:
"Would you like it if we discussed the transfer with your family member?"
This response facilitates therapeutic communication and provides general leads while
maintaining client confidentiality.
Incorrect Answers:
"The transfer of your family member is being done because the provider knows what's best."
This is a defensive response which can hinder further communication.
"Why are you so concerned about this transfer?"
Asking a why question can make the recipient defensive which can hinder further
communication.
"I know how you feel. My parent had to be transferred to a long-term care facility."
This is a sympathetic response, which can interfere with a therapeutic relationship.
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of
the following laboratory result would be a priority for the nurse report to the provider?
BUN 21 mg/dL (10 to 20 mg/dL)
Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)
Sodium 132 mEq/L (136 to 145 mEq/L)
Potassium 5.8 mEq/L (3.5 to 5 mEq/L) - Correct Answer:
Potassium 5.8 mEq/L (3.5 to 5 mEq/L)
When using the urgent versus nonurgent approach to client care, the nurse should determine
that this potassium level is above the expected reference range and should be reported to the
provider. Potassium affects the contractility of the heart and this client would be at risk for
developing dysrhythmias.
Incorrect answers:
BUN 21 mg/dL (10 to 20 mg/dL)
This BUN level is slightly above the expected reference range and is an expected non-urgent
finding for a client who has hypovolemia; therefore, there is another laboratory result that is a
priority for the nurse to report to the provider.
Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)
This creatinine level is slightly above the expected reference range and is an expected nonurgent finding for a client who has hypovolemia; therefore, there is another laboratory result
that is a a priority for the nurse to report to the provide [Show Less]