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 C

Explanation

A. Is aware that some health problems affect clients from various social levels: While being aware of health disparities related to social factors is important for providing comprehensive care, it does not fully capture the professional value of social justice. Social justice involves more than just awareness; it entails taking action to address inequalities and ensure fair treatment and access to care for all individuals, regardless of their background.

B. Does safe, research-based interventions for clients: While providing safe, evidence-based interventions is a fundamental aspect of nursing practice, it does not directly relate to the professional value of social justice. Social justice focuses on addressing systemic barriers and inequalities in healthcare to ensure equitable treatment and access for all individuals, rather than solely on the delivery of interventions.

C. Ensures equal treatment & access to care regardless of clients' background: This option best describes the professional value of social justice. Nurses who uphold social justice advocate for fair and equal treatment of all individuals, regardless of factors such as socioeconomic status, race, ethnicity, gender, or sexual orientation. They work to identify and address systemic barriers that contribute to health disparities and advocate for policies and practices that promote equitable access to healthcare services.

D. Collects data about unique needs of individual clients prior to planning care: While collecting data about clients' unique needs is essential for providing individualized care, it does not directly relate to the professional value of social justice. Social justice focuses on broader systemic issues and ensuring fair treatment and access to care for all individuals, rather than solely on individualized care planning.

A. Serum osmolarity B. Urinary output C. Insensible fluid loss D. Blood pressure

Correct Answer is B

Explanation

When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.

A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.

B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.

C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.

D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.

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

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Naxlex Comprehensive Predictor Exams

What is the best description for the professional value of social justice? The nurse…

Correct Answer is C

Explanation

A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?

Correct Answer is B

Explanation

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