A nurse is caring for a client who is receiving fluid replacement therapy following a postpartum hemorrhage. Which of the following findings Indicate the client's fluid balance has been restored?
Peripheral edema is present.
Crackles upon auscultation of the lungs
Maternal heart rate is 110/min.
Urine output for 1 hour is 35 mL.
The Correct Answer is D
Rationale:
A. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.
B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.
C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.
D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","G","H","I"]
Explanation
Rationale for correct choices
• 61-year-old male: Advanced age and male sex increase the risk of cardiovascular complications such as coronary artery disease, heart failure, and stroke. Aging contributes to arterial stiffness, reduced cardiac reserve, and higher likelihood of comorbidities, all of which elevate the risk profile for this client.
• Has smoked 1 pack of cigarettes per day for 40 years: Chronic smoking is a major modifiable risk factor for atherosclerosis, myocardial infarction, stroke, and peripheral arterial disease. Long-term tobacco use promotes endothelial damage, increases LDL cholesterol, and impairs oxygen delivery, significantly increasing cardiovascular risk.
• History of hyperlipidemia: Elevated cholesterol and triglycerides predispose the client to plaque formation in arteries, contributing to atherosclerosis and cardiovascular disease. Hyperlipidemia is a key risk factor for complications such as myocardial infarction and stroke, especially when combined with other comorbidities.
• Reports drinking two to three beers each evening: Excessive alcohol consumption contributes to hypertension, cardiomyopathy, and arrhythmias. Chronic alcohol intake can also exacerbate hyperlipidemia and increase the risk of liver disease, compounding cardiovascular and systemic complications.
• BMI 30.5: A BMI above 30 classifies the client as obese, which increases the risk for hypertension, type 2 diabetes, heart disease, and stroke. Obesity contributes to metabolic syndrome and further stresses the cardiovascular system, making the client more prone to complications.
• Family history: Biological father with hyperlipidemia and hypertension, Biological mother with renal failure: A strong family history of cardiovascular and renal disease increases the client’s genetic susceptibility to these conditions. Inherited risk factors, when combined with lifestyle factors, significantly elevate the likelihood of developing complications such as heart failure, chronic kidney disease, or stroke.
Rationale for incorrect choices
• Walks at least a mile three times a week: Regular physical activity is protective, not a risk factor, for cardiovascular and metabolic complications. Exercise helps improve lipid profile, blood pressure, and overall cardiovascular health, mitigating some of the client’s other risk factors.
• Client reports he follows the DASH diet: Adhering to the DASH diet is a positive lifestyle behavior that reduces blood pressure, supports heart health, and lowers the risk of stroke or heart disease. It is not a risk factor; rather, it is a mitigating factor against cardiovascular complications.
Correct Answer is A
Explanation
Rationale:
A. "You should not drink through a straw for 2 weeks.": Drinking through a straw can create pressure in the middle ear, which may dislodge the tympanic membrane graft or interfere with healing after a myringotomy. Avoiding straws is an important precaution to protect the surgical site and promote proper recovery.
B. "You should expect excessive ear drainage for about 48 hours": Some drainage may occur, but excessive drainage is not expected and could indicate infection or complications. Clients should be instructed to report any abnormal or persistent drainage to the provider rather than expecting it as normal.
C. "You can wash your hair 3 days after the procedure.": Hair washing is typically delayed until the provider confirms it is safe, usually after avoiding water in the ear for a few days. Premature washing could allow water to enter the middle ear, increasing the risk of infection.
D. "You should blow your nose with your mouth closed": Blowing the nose increases pressure in the middle ear and can compromise the healing of the tympanic membrane. Clients should be taught to avoid nose-blowing entirely or do so gently with the mouth open if necessary.
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