A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Serum K+ 3.6 mEq/L

Urine specific gravity of 1.012

Respiratory rate 18

+4 Pedal Pulses

Answer and Explanation

The Correct Answer is D

A. Serum K+ 3.6 mEq/L: Serum potassium (K+) level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically validate fluid volume excess. Serum electrolyte levels can be affected by various factors, including hydration status, renal function, and medications. While hypokalemia (low potassium) may be associated with conditions such as diuretic use or excessive fluid loss, it is not a definitive indicator of fluid volume excess.

B. Urine specific gravity of 1.012: Urine specific gravity measures the concentration of solutes in the urine and can provide information about the client's hydration status. A specific gravity of 1.012 is within the normal range (typically 1.005 to 1.030), indicating that the urine is neither extremely concentrated nor dilute. While changes in urine specific gravity may suggest alterations in fluid balance, a single measurement alone may not be sufficient to validate the client's fluid status, especially in the context of fluid volume excess.

C. Respiratory rate 18: A respiratory rate of 18 breaths per minute falls within the normal range for adults (12-20 breaths per minute) and does not specifically indicate fluid volume excess. Changes in respiratory rate may occur in response to various factors, including respiratory, cardiovascular, or metabolic conditions, but it is not a direct indicator of fluid volume status.

D. +4 Pedal Pulses:

The presence of +4 pedal pulses indicates strong, bounding pulses in the feet. This finding suggests adequate perfusion to the peripheral extremities, which may indicate an appropriate fluid balance. In clients with fluid volume excess, maintaining adequate perfusion to peripheral tissues is essential to prevent complications such as peripheral edema and impaired tissue oxygenation. Strong pedal pulses suggest that perfusion to the lower extremities is not compromised due to hypovolemia or decreased cardiac output, which can be associated with fluid volume deficit.

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Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

A. lithotomy with a drape for privacy B. Supine with arms at their sides C. left decubitus D. a position that feels most comfortable for the client

Correct Answer is B

Explanation

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

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