A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Serum calcium 10 mg/dL

Urine specific gravity 1.001

Serum sodium 138 mEq/L

Urine pH 6.1

Answer and Explanation

The Correct Answer is B

A. Serum calcium levels are not directly indicative of hypervolemia.

B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.

C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.

D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.

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Correct Answer is A

Explanation

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.

A. The client tucks his chin while swallowing food. B. The client sits upright in bed during meals. C. The client pockets food on one side of his mouth. D. The client has a cough reflex.

Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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