A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?
Distended neck veins.
Poor skin turgor.
Concentrated hemoglobin and hematocrit levels.
Decreased urine output.
The Correct Answer is A
Choice A rationale:
Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.
Choice B rationale:
Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.
Choice C rationale:
Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.
Choice D rationale:
Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is choice A, C, and D.
Choice A rationale:
Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.
Choice B rationale:
Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.
Choice C rationale:
Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.
Choice D rationale:
Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.
Choice E rationale:
Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.
Correct Answer is D
Explanation
25 mg/dL.
Choice A rationale:
A BUN (Blood Urea Nitrogen) level of 10 mg/dL is within the normal range, indicating normal kidney function. There is no indication to report this value to the provider for a dehydrated client.
Choice B rationale:
A BUN level of 18 mg/dL is within the normal range as well. This value does not suggest significant dehydration, so it is not necessary to report it to the provider in this context.
Choice C rationale:
A BUN level of 13 mg/dL is also within the normal range, and similar to choices A and B, it does not indicate severe dehydration that requires immediate reporting to the provider.
Choice D rationale:
A BUN level of 25 mg/dL is elevated, which may indicate dehydration, kidney dysfunction, or other issues affecting fluid balance. Since the client is dehydrated, this elevated value needs to be reported to the provider for further evaluation and appropriate intervention.
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