Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Heart rate 99 beats/minute

Dark, yellow urine

Urinated 30 mL

Temperature 101° F (38.3° C)

Answer and Explanation

Correct Answer : A,B,C

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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Correct Answer is C

Explanation

A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.

Correct Answer is ["0.6"]

Explanation

Medication dose: 30 mg enoxaparin
Medication concentration: 30 mg per 0.3 mL (prefilled syringe)
Frequency: Every 12 hours
Duration: 10 days

Calculation:

Injections per day: Since the medication is given every 12 hours, the client will receive injections 2 times per day (24 hours / 12 hours/injection).
Total medication per day: To find the total amount of enoxaparin needed per day, multiply the single injection dose by the number of injections:

Total enoxaparin/day = Dose per injection x Number of injections/day = 30 mg/injection x 2 injections/day = 60 mg/day

Volume of medication per day: Now, we need to find the volume of solution needed to deliver the total daily dose (60 mg) based on the medication concentration (30 mg/0.3 mL). We can achieve this with a proportion:

Volume (mL) / Total dose (mg) = Concentration (mg/mL)

Volume (mL) = (Total dose (mg) x Concentration (mL/mg)) / Concentration (mg/mL)

Plugging in the values:

Volume (mL) = (60 mg x 0.3 mL/mg) / 30 mg/mL

Volume (mL) = 18 mL / 30 mL/mL

Simplifying:

Volume (mL) = 0.6 mL

Therefore, the practical nurse (PN) should administer 0.6 mL of enoxaparin each day.

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Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

Correct Answer is C

Explanation

A client who had a knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)

Correct Answer is ["0.6"]

Explanation

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Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?