A nurse is feeding a client who has heart failure. Which of the following findings indicates that the client is gaining fluid volume excess?
Creatinine 1.3 mg/dL
BNP 300 pg/mL
Potassium 3.5 mEq/L
Sodium 140 mEq/L
The Correct Answer is B
Choice A reason: Creatinine 1.3 mg/dL is slightly elevated, but it does not indicate fluid volume excess. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: BNP 300 pg/mL is high and indicates fluid volume excess. BNP stands for brain natriuretic peptide, which is a hormone released by the heart when it is stretched by increased blood volume or pressure. High BNP levels can indicate heart failure or fluid overload.
Choice C reason: Potassium 3.5 mEq/L is within the normal range (3.5-5.0), and it does not indicate fluid volume excess. Potassium is an electrolyte that helps regulate nerve and muscle function, especially the heart. Low or high potassium levels can cause cardiac arrhythmias, muscle weakness, or paralysis.
Choice D reason: Sodium 140 mEq/L is within the normal range (135-145), and it does not indicate fluid volume excess. Sodium is an electrolyte that helps maintain fluid balance, blood pressure, and nerve impulses. Low or high sodium levels can cause confusion, seizures, or coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: 1 cup green grapes has about 15 mg of calcium, which is low compared to other foods. Green grapes are also a good source of vitamin C, potassium, and antioxidants.
Choice B reason: One medium banana has about 6 mg of calcium, which is very low compared to other foods. Banana is also a good source of potassium, fiber, and vitamin B6.
Choice C reason: 1 cup broccoli has about 180 mg of calcium, which is high compared to other foods. Broccoli is also a good source of vitamin C, folate, and antioxidants.
Choice D reason: One large tomato has about 18 mg of calcium, which is low compared to other foods. Tomato is also a good source of vitamin C, lycopene, and potassium.
Correct Answer is D
Explanation
Choice A reason: A pump is usually needed to administer intermittent tube feedings, as it can control the flow rate and volume of the formula. A pump can also prevent overfeeding, aspiration, or diarrhea.
Choice B reason: Administering feedings over 10 to 20 minutes is too fast, as it can cause abdominal cramps, nausea, vomiting, or dumping syndrome. Intermittent tube feedings should be administered over 30 to 60 minutes.
Choice C reason: Administering feedings while sleeping at night is not recommended, as it can increase the risk of aspiration, reflux, or infection. Intermittent tube feedings should be administered during waking hours and with the head of the bed elevated at least 30 degrees.
Choice D reason: Advancing the rate of feedings slowly is advisable, as it can help the body adjust to the formula and prevent intolerance or complications. The rate should be increased gradually until the desired goal is reached.
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