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 ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. Slide hands under the client's lumbar area and knees. B. Turn the client away from the PN using a turning sheet. C. Put the bed rails up on the opposite side of the bed. D. Grasp the client's hand to pull the client towards the PN.

Correct Answer is B

Explanation

A. Sliding hands under the lumbar area and knees can cause strain on the PN’s back and is not the safest method for turning a dependent client.
B. Using a turning sheet to turn the client away from the PN is the safest method for moving a dependent client, as it uses a proper technique that minimizes injury risk for both the client and the PN.
C. Raising bed rails on the opposite side may increase the risk of injury or falls, and is not directly related to the safe turning of the client.
D. Grasping the client's hand to pull them is unsafe and could cause injury or discomfort to both the client and the PN, especially when turning a dependent client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

The practical nurse (PN) is turning a dependent bedridden client without assistance. Which action will best ensure the client's safety?

Correct Answer is B

Explanation

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The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location? (Select the correct location on the image)

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?