A nurse is reviewing the medical record of a client who has heart failure and is experiencing fluid volume excess without an electrolyte imbalance. Which of the following findings should the nurse expect?

Increased urine specific gravity

Polyuria

Pericardial friction rub

Distended neck veins

Answer and Explanation

The Correct Answer is D

Rationale:

A. Increased urine specific gravity: In fluid volume excess, the urine is often dilute due to increased renal perfusion or diuretic use, leading to a decreased specific gravity. An increased specific gravity is more commonly associated with dehydration or fluid volume deficit.

B. Polyuria: While polyuria can occur with certain conditions like diabetes mellitus or diabetes insipidus, it is not a typical finding in heart failure with fluid volume excess. Fluid is often retained rather than excreted in these clients unless diuretics are being administered.

C. Pericardial friction rub: A pericardial friction rub indicates pericarditis, an inflammation of the pericardial sac, and is not a typical manifestation of fluid volume excess in heart failure. It is unrelated to fluid overload.

D. Distended neck veins: Jugular vein distention is a hallmark sign of fluid volume excess and elevated central venous pressure, commonly seen in clients with heart failure. It indicates poor venous return and systemic fluid congestion.

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Correct Answer is D

Explanation

Rationale:

A. Provide nasotracheal suctioning for the adolescent every 4 hr: Routine suctioning can increase intracranial pressure (ICP) due to stimulation of the airway. It should only be done when absolutely necessary and performed with caution in clients with elevated ICP.

B. Place the adolescent on contact precautions for 48 hr: Bacterial meningitis requires droplet precautions, not contact precautions. Droplet precautions should be maintained until 24 hours after the initiation of effective antibiotic therapy, not strictly for 48 hours.

C. Perform passive range-of-motion exercises for the adolescent prior to administering sedation: While mobility is important, performing exercises before sedation is not a priority intervention when managing increased ICP. Activity may actually raise ICP, so it should be limited during the acute phase.

D. Maintain the head of the adolescent's bed at a 20° angle: Elevating the head of the bed helps promote venous return from the brain and reduces ICP. Keeping the head midline and the bed slightly elevated is a key intervention in managing clients with increased ICP.

A. Obtain a urinalysis for the client every 3 days. B. A urinary catheter will be in place for several weeks. C. Expect blood to be present in the urine after surgery. D. Clamp the client's urinary catheter for 20 min every 1 hr.

Correct Answer is C

Explanation

Rationale:

A. Obtain a urinalysis for the client every 3 days: Post-kidney transplant patients require frequent monitoring for signs of infection or rejection, especially in the first few days. Waiting 3 days between urinalyses may delay the detection of complications.

B. A urinary catheter will be in place for several weeks: Indwelling catheters are typically maintained for a few days postoperatively to monitor urine output, but prolonged use increases infection risk. Several weeks would be excessive unless complications arise.

C. Expect blood to be present in the urine after surgery: Hematuria is common immediately after kidney transplantation due to surgical manipulation and healing of the urinary tract. It usually resolves within a few days and is a normal early postoperative finding.

D. Clamp the client's urinary catheter for 20 min every 1 hr: Clamping the catheter can increase intravesical pressure and compromise graft function. Continuous urine drainage is preferred to allow for accurate monitoring and to reduce pressure on the new kidney.

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A nurse is reviewing the medical record of a client who has heart failure and is experiencing fluid volume excess without an electrolyte imbalance. Which of the following findings should the nurse expect?

Nursing Test Bank

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