The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?
Urine specific gravity 1.012.
+4 Pedal pulses.
Respiratory rate 20/minute.
Potassium level 3.8 mEq/L.
The Correct Answer is A
Choice A rationale
Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.
Choice B rationale
+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.
Choice C rationale
A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.
Choice D rationale
A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
After a femoral-popliteal bypass, the client should be placed in a supine position with the right leg extended and flat. This position helps to prevent kinking and occlusion of the graft, which could lead to complications such as graft thrombosis.
Choice B rationale
High-Fowler’s position with the right leg extended is not recommended. This position could put strain on the surgical site and potentially compromise the graft.
Choice C rationale
Supine with the right leg flexed at a 45-degree angle is not advised. Flexing the leg could lead to kinking of the graft and subsequent complications.
Choice D rationale
Semi-Fowler’s with the right leg on two pillows is not the optimal position. While elevation can help with swelling, excessive elevation could potentially compromise blood flow to the graft.
Correct Answer is A
Explanation
Choice A rationale
Trimethoprim-sulfamethoxazole is an antibiotic used to treat or prevent bacterial infections. One of the key instructions for patients taking this medication is to increase fluid intake to 3 to
4 liters per 24 hours. This is because the medication can crystallize in the urine, which can lead to kidney stones or damage if the patient is not adequately hydrated.
Choice B rationale
Spending time in the sun does not improve the metabolism of trimethoprim-sulfamethoxazole. In fact, the medication can make the skin more sensitive to the sun, increasing the risk of sunburn.
Choice C rationale
Taking Kaopectate daily to prevent diarrhea is not a standard instruction for patients taking trimethoprim-sulfamethoxazole. Diarrhea can be a side effect of the medication, but it should be managed under the guidance of a healthcare provider.
Choice D rationale
There is no specific instruction to take trimethoprim-sulfamethoxazole every morning at the same time as hydrochlorothiazide. The timing of medication administration should be determined by the healthcare provider based on the patient’s overall treatment plan.
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