A nurse is collecting data from a client who is receiving IV fluids for dehydration. Which of the following findings should indicate to the nurse the client is experiencing fluid volume excess?

The client has tenting after pinching the skin on the hand.

The client's urinary output is 25 mL/hr for the past 4 hr.

The client experiences orthostatic hypotension when moving to a standing position.

The client has distended neck veins when moved to an upright position.

Answer and Explanation

The Correct Answer is D

A. The client has tenting after pinching the skin on the hand:
Skin tenting is a sign of dehydration, not fluid volume excess.

B. The client's urinary output is 25 mL/hr for the past 4 hr:
Low urine output (oliguria) indicates dehydration or kidney impairment, not fluid overload.

C. The client experiences orthostatic hypotension when moving to a standing position:
Orthostatic hypotension is more common in dehydration or blood loss.

D. The client has distended neck veins when moved to an upright position:
Jugular vein distention in an upright position is a classic sign of fluid volume excess due to increased venous pressure.

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Correct Answer is ["A","B","C"]

Explanation

A. Client 1 (Neisseria gonorrhoeae) :
Gonorrhea is a reportable sexually transmitted infection due to public health tracking and prevention requirements.

B. Client 2 (Chlamydia trachomatis) :
Chlamydia is a reportable STI because it is highly prevalent and can cause serious reproductive health complications.

C. Client 3 (Syphilis) :
Syphilis is a reportable STI due to its public health significance and need for contact tracing.

D. Client 4 (Human papillomavirus / Condyloma acuminata):
HPV is not a reportable condition in most jurisdictions because of its high prevalence and self-limiting nature in many cases.

E. Client 5 (Genital Herpes Simplex Virus type 2):
HSV is not typically a reportable condition in most jurisdictions, though education and counseling are important for prevention.

A. Ask the provider to give consent for the transfusion. B. Respect the daughter's decision to refuse the transfusion. C. Encourage the daughter to let her mother have the transfusion. D. Discuss taking guardianship of the client with the facility administration.

Correct Answer is B

Explanation

A. Ask the provider to give consent for the transfusion:
Providers cannot override a legally authorized healthcare proxy when the client lacks decision-making capacity.

B. Respect the daughter's decision to refuse the transfusion:
A durable power of attorney for health care grants the designated individual legal authority to make decisions when the client is unable to do so, even if it means refusing treatment.

C. Encourage the daughter to let her mother have the transfusion:
This may be perceived as coercive and disregards the daughter’s legal decision-making authority.

D. Discuss taking guardianship of the client with the facility administration:
Guardianship is not needed when a valid durable power of attorney for health care is in place.

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A nurse is collecting data from a client who is receiving IV fluids for dehydration. Which of the following findings should indicate to the nurse the client is experiencing fluid volume excess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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