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. "I shouldn't take my vitamin D pill before the stool sample is collected." Vitamin D supplements are unlikely to interfere with the hemoccult test, as they typically do not contain substances that affect the detection of occult blood in the stool. Therefore, this statement does not demonstrate an understanding of factors relevant to the stool sample collection for the hemoccult test.

B. "I should take a laxative to help me pass my stool." Taking a laxative before collecting the stool sample is not recommended, as it can alter the consistency and composition of the stool, potentially affecting the accuracy of the hemoccult test. Laxatives may also cause diarrhea, leading to difficulty in collecting a sufficient sample. Therefore, this statement is incorrect and does not reflect effective teaching regarding stool sample collection for the hemoccult test.

C. "I must avoid drinking milk before collecting the stool sample." While certain dietary restrictions may be necessary for specific diagnostic tests, drinking milk is not typically prohibited before collecting a stool sample for a hemoccult test. Milk consumption is unlikely to interfere with the test results or the detection of occult blood in the stool. Therefore, this statement is not relevant to the hemoccult test and does not demonstrate understanding of appropriate preparation for the test.

D. "Any meat that I eat before I collect my stool sample must be fully cooked." This statement reflects an understanding of food safety and hygiene practices relevant to stool sample collection for the hemoccult test. Fully cooked meat reduces the risk of bacterial contamination in the stool sample, which could interfere with the accuracy of the test results. Therefore, this statement demonstrates effective teaching regarding the importance of food preparation in ensuring accurate test results for the hemoccult test.

A. always has a religious connotation. B. is a narrower concept than religion. C. does not necessarily include religion. D. has been created by humans to define ethical conduct.

Correct Answer is C

Explanation

A. always has a religious connotation: This statement is incorrect. While spirituality can be intertwined with religion for many individuals, it does not always have a religious connotation. Spirituality encompasses a broader sense of connection to something greater than oneself, which may or may not be associated with organized religion.

B. is a narrower concept than religion: This statement is incorrect. Spirituality is often considered a broader concept than religion. While religion typically involves organized beliefs, rituals, and practices within a specific faith tradition, spirituality encompasses a wider range of experiences, beliefs, and practices that relate to the search for meaning, purpose, and connection to the transcendent.

C. does not necessarily include religion: This statement is correct. Spirituality can exist independently of religion. While religion often involves spirituality, spirituality can encompass a wide range of beliefs, experiences, and practices that may or may not be connected to organized religion. Individuals can experience spirituality through various means such as nature, relationships, art, meditation, and personal reflection, regardless of religious affiliation.

D. has been created by humans to define ethical conduct: This statement is incorrect. Spirituality is not solely created by humans to define ethical conduct. While ethical principles and values may be part of spiritual beliefs for many individuals, spirituality encompasses broader aspects of human experience, including the search for meaning, connection, and transcendence, which extend beyond ethical conduct.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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