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 A

Explanation

Rationale:
A. A pearly, waxy nodule: This is the classic presentation of basal cell carcinoma. These lesions often appear as small, shiny, flesh-colored or pink nodules with a translucent or pearly surface and may have visible blood vessels. They are slow-growing and rarely metastasize.

B. An irregular border on a variegated-colored lesion: This description is more indicative of malignant melanoma, which often appears as an asymmetric lesion with uneven borders and multiple colors, including black, brown, red, or white.

C. A firm, nodular, crusty, or ulcerated lesion: These characteristics are more commonly associated with squamous cell carcinoma, which tends to be more aggressive and can metastasize if untreated.

D. A weeping vesicle: This finding is consistent with inflammatory skin conditions such as contact dermatitis or eczema, not basal cell carcinoma. These vesicles are usually associated with allergic or irritant reactions.

A. Stop the blood transfusion immediately. B. Prepare to administer antipyretics. C. Monitor the client for any adverse reactions. D. Transfuse the blood over 6 hr.

Correct Answer is C

Explanation

Rationale:
A. Stop the blood transfusion immediately: There is no need to stop the transfusion, as type B negative blood is compatible with AB positive recipients. AB positive individuals are universal recipients and can safely receive red blood cells from any ABO and Rh-negative or Rh-positive blood type.

B. Prepare to administer antipyretics: Antipyretics are not required unless the client shows signs of a febrile reaction. There is no indication from the question that the client is experiencing such symptoms.

C. Monitor the client for any adverse reactions: This is the appropriate action. Although the blood type is compatible, it is standard protocol to closely monitor all clients during transfusion for signs of adverse reactions, especially within the first 15 minutes.

D. Transfuse the blood over 6 hr: Blood transfusions should be completed within 4 hours to reduce the risk of bacterial growth and hemolysis. Extending the transfusion to 6 hours violates safety guidelines.

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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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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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