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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F","G"]
Explanation
Rationale:
A. Administer morphine 4 mg IV bolus: Morphine is appropriate for severe chest pain unrelieved by nitrates. It decreases preload, pain, and anxiety, reducing myocardial oxygen demand. This intervention helps improve comfort and may lower sympathetic nervous system activation during an acute MI.
B. Prepare client for an exercise tolerance test: This is contraindicated during active chest pain and elevated troponin levels. Stress testing would increase cardiac workload and worsen ischemia. It is only done when a patient is stable and MI has been ruled out.
C. Administer an intermittent IV fluid bolus: Fluid boluses are not indicated unless hypotension or hypovolemia is present. Extra fluid can increase cardiac workload and worsen outcomes in MI. In a normotensive patient with chest pain, it offers no benefit and may increase risk of pulmonary congestion.
D. Administer nitroglycerin sublingual: Nitroglycerin is a first-line medication for ischemic chest pain. It improves blood flow by dilating coronary arteries and reducing cardiac preload. It can rapidly relieve angina and should be administered as soon as possible in acute chest pain.
E. Place the client in the supine position: Supine positioning may worsen breathing difficulty and is not ideal during acute chest pain. A semi-Fowler's position is better to support oxygenation. Keeping the head elevated helps reduce venous return and cardiac workload.
F. Apply oxygen at 2 L/min via nasal cannula: Oxygen is appropriate with labored respirations and signs of hypoxia. It improves oxygen delivery to the myocardium during ischemic events. Supplemental oxygen can help stabilize oxygen saturation while definitive interventions are underway.
G. Prepare client for percutaneous coronary intervention: PCI is a key treatment for myocardial infarction and should be anticipated given the client’s chest pain, elevated troponin, and high risk profile. It restores perfusion to the affected coronary artery and reduces infarct size and mortality when performed promptly.
Correct Answer is C
Explanation
Rationale:
A. The client's bed has a three-prong plug attached to the electrical cord: A three-prong plug provides grounding and is a standard safety feature. It helps prevent electric shock and is not considered a hazard.
B. A protective cover is inserted into an unused outlet: Outlet covers are recommended, especially in homes with children, to prevent accidental electrical shock. This is a safety measure, not a hazard.
C. An IV pump is plugged into an outlet near a sink: This is a safety hazard because electrical devices should not be used near water sources. The proximity to the sink increases the risk of electrical shock or short-circuiting if moisture contacts the outlet or device.
D. An electrical cord is coiled and secured to the floor: Coiling and securing cords can prevent tripping hazards and is generally acceptable as long as the cord is not damaged or covered in a way that could lead to overheating.
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