The nurse assesses a client with suspected fluid volume overload. Which finding should the nurse expect?

Crackles in the lung bases

Hemoglobin of 19.2 g/dL

Blood pressure of 92/64 mmHg

Weak peripheral pulses

Answer and Explanation

The Correct Answer is A

Choice A reason:
Fluid volume overload leads to excess fluid in the intravascular and interstitial spaces. When fluid accumulates in the lungs, it causes pulmonary congestion, which is auscultated as crackles, particularly in the lung bases. This is a classic and expected assessment finding in fluid volume overload.

Choice B reason:
A hemoglobin level of 19.2 g/dL indicates hemoconcentration, which is more commonly associated with fluid volume deficit rather than overload. In fluid volume overload, hemodilution typically occurs, resulting in decreased hemoglobin and hematocrit levels.

Choice C reason:
A blood pressure of 92/64 mmHg suggests hypotension, which is more consistent with hypovolemia or shock. Fluid volume overload usually leads to increased blood pressure due to expanded intravascular volume, not decreased blood pressure.

Choice D reason:
Weak peripheral pulses are commonly seen in fluid volume deficit due to decreased circulating volume. In fluid volume overload, pulses are more likely to be bounding as a result of increased intravascular volume and pressure.

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Correct Answer is C

Explanation

Choice A reason:
This option reflects the ethical principle of fidelity, which refers to faithfulness, loyalty, and keeping commitments made to clients. Fidelity emphasizes maintaining trust, honoring promises, and being truthful in professional relationships. While fidelity is essential to ethical nursing practice, it does not specifically address the prevention of harm. Therefore, this choice does not best define the obligation to avoid causing harm to a client.

Choice B reason:
This option corresponds to the ethical principle of justice, which focuses on fairness, equity, and the appropriate distribution of resources among clients and populations. Justice ensures that all clients receive impartial and equal treatment regardless of personal characteristics or social status. Although justice is a core ethical principle, it is centered on fairness rather than the direct prevention of harm, making it an incorrect choice for this question.

Choice C reason:
This option accurately represents the ethical principle of nonmaleficence. Nonmaleficence is defined as the obligation to avoid causing harm, injury, or unnecessary suffering to clients. In nursing practice, this principle guides clinicians to carefully evaluate interventions, anticipate potential risks, and avoid actions that could negatively impact client safety or well-being. Because the question specifically asks about the obligation to avoid harm, this is the most accurate and correct answer.

Choice D reason:
This option reflects the ethical principle of beneficence, which involves taking positive actions to promote good, support client welfare, and improve health outcomes. Beneficence encourages nurses to act in the best interest of the client by providing compassionate and beneficial care. However, beneficence is distinct from nonmaleficence, as it focuses on doing good rather than specifically avoiding harm. For this reason, it is not the best answer to the question.

A. Mild discomfort to the left side of the neck. B. Visible blood in the catheter when checking patency. C. Presence of an antimicrobial disk at the insertion site. D. Absent breath sounds over the left lung field.

Correct Answer is D

Explanation

Choice A reason:
Mild discomfort near the insertion site is an expected finding after central line placement due to local tissue irritation. This can be managed with routine comfort measures and does not require immediate intervention.

Choice B reason:
The presence of blood return when checking catheter patency indicates that the line is properly positioned within the vascular system. This is an expected and desired finding, not a complication.

Choice C reason:
An antimicrobial disk at the insertion site is a preventive measure used to reduce the risk of catheter-related bloodstream infections. Its presence is appropriate and does not indicate a problem.

Choice D reason:
Absent breath sounds on the same side as a recently inserted subclavian central line strongly suggest a pneumothorax, a potentially life-threatening complication caused by accidental puncture of the lung. This finding requires immediate action to prevent respiratory compromise.

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The nurse assesses a client with suspected fluid volume overload. Which finding should the nurse expect?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing ethical principles that guide professional nursing practice. Which ethical principle is best defined as the obligation to avoid causing harm to a client?

Correct Answer is C

Explanation

A nurse is caring for a client with a newly inserted left subclavian central line. What assessment finding one hour after insertion warrants immediate action by the nurse?

Correct Answer is D

Explanation

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The nurse is reviewing ethical principles that guide professional nursing practice. Which ethical principle is best defined as the obligation to avoid causing harm to a client?