A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

Urine specific gravity 1.015

Hematocrit 42%

Urine pH 6.5

BUN 5 mg/dL

Answer and Explanation

The Correct Answer is D

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

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Correct Answer is C

Explanation

A. Discontinued medications do not provide actionable information for the receiving facility, as they are no longer relevant to the client's ongoing care. Including this information may lead to confusion about the current treatment plan.
B. Resolved health conditions are not a priority to communicate because they do not require further monitoring or intervention. Focus should be placed on active health concerns and ongoing care needs.
C. The frequency of vital sign collection is critical information for the receiving facility to maintain continuity of care and ensure appropriate monitoring of the client's condition. This detail helps guide the long-term care staff in managing the client’s ongoing health needs effectively.
D. Completed nursing interventions are not typically included in the transfer report as they have already been addressed and do not impact future care. The focus should remain on ongoing and future interventions required for the client.

A. The client's body should be placed on the floor. B. The client's oldest child will bathe the body. C. The client's face should be turned toward Mecca. D. The client's body will be adorned with amulets.

Correct Answer is C

Explanation

A. The client's body should be placed on the floor: This is not a specific cultural practice in Islam. In Islamic tradition, the deceased person is usually placed on a raised surface, like a table or bed, to allow family and friends to gather around for prayers and final respects.

B. The client's oldest child will bathe the body: This is not a specific cultural practice in Islam.

In Islamic tradition, the body is usually washed by individuals of the same gender who are experienced in the ritual washing of the deceased, known as "Ghusl."

C. The client's face should be turned toward Mecca: Correct. In Islamic tradition, when a person dies, it is customary to position the body with the head facing the Kaaba in Mecca, which is the holy city in Islam and the direction toward which Muslims pray.

D. The client's body will be adorned with amulets: This is not a specific cultural practice in Islam. While some individuals in various cultures may use amulets or charms for protection, it is not a universal Islamic practice for the deceased.

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A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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