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. [Show Less]