A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?

BUN 16 mg/dL (10 to 20 mg/dL)

Urine output 40 mL every hour for 3 hr

Hct 42% (37% to 47%)

Surgical drain output 300 mL during an 8-hr shift

Answer and Explanation

The Correct Answer is D

Rationale:
A. BUN 16 mg/dL (10 to 20 mg/dL): This is a normal blood urea nitrogen level and does not indicate dehydration or fluid volume deficit. Elevated BUN may suggest volume depletion, but this value is within the expected range.

B. Urine output 40 mL every hour for 3 hr: A urine output of 30 mL/hr or greater is considered adequate in most adult clients. Therefore, 40 mL/hr is within acceptable limits and does not suggest fluid volume deficit.

C. Hct 42% (37% to 47%): This hematocrit level falls within the normal range and does not indicate hemoconcentration. Elevated hematocrit could signal dehydration, but this value alone does not support that conclusion.

D. Surgical drain output 300 mL during an 8-hr shift: This is a significant amount of fluid loss postoperatively and can contribute to fluid volume deficit. High drain output following surgery, especially spinal procedures, increases the client's risk for hypovolemia and should be closely monitored.

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Correct Answer is D

Explanation

Rationale:
A. N95 respirator: N95 respirators are required for airborne precautions, such as with tuberculosis, measles, or varicella. Bacterial meningitis, caused by organisms like Neisseria meningitidis, requires droplet precautions, which do not necessitate an N95 mask.

B. Goggles: Goggles are used for protection against splashes or sprays of bodily fluids, particularly in procedures that may cause aerosolization. While helpful in certain situations, goggles are not required as part of standard droplet precautions for meningitis.

C. Disposable gown: Gowns are worn during contact precautions or when there is a risk of contamination from bodily fluids. They are not routinely required for droplet precautions unless the nurse anticipates contact with large amounts of secretions.

D. Surgical mask: A surgical mask is the appropriate PPE for droplet precautions, which are necessary for clients with bacterial meningitis. The mask prevents the spread of infectious respiratory droplets that can travel up to 3 feet during coughing or sneezing.

A. Wear a protective gown when suctioning the client's airway. B. Monitor for oral secretions every 2 hr. C. Provide oral care every 2 hr. D. Maintain the client in a supine position. E. Assess the client daily for readiness of extubation.

Correct Answer is ["B","C","E"]

Explanation

Rationale:
A. Wear a protective gown when suctioning the client's airway: While wearing appropriate personal protective equipment protects the nurse from contamination, it does not directly reduce the client’s risk for ventilator-associated pneumonia.

B. Monitor for oral secretions every 2 hr: Regular assessment for and removal of oral secretions reduces the risk of aspiration, which is a key contributor to the development of ventilator-associated pneumonia.

C. Provide oral care every 2 hr: Frequent oral hygiene decreases the colonization of bacteria in the oropharynx, thereby reducing the risk of these organisms being aspirated into the lungs and causing infection.

D. Maintain the client in a supine position: Keeping the client supine increases the risk of aspiration. To prevent VAP, the head of the bed should typically be elevated 30 to 45 degrees unless contraindicated.

E. Assess the client daily for readiness of extubation: Daily evaluation for weaning from the ventilator reduces the duration of mechanical ventilation, which directly lowers the risk of developing ventilator-associated pneumonia.

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A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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