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 C
Explanation
Choice A rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.
Choice B rationale
Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.
Choice C rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is demonstrating good control of blood glucose.
Choice D rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hyperglycemia.
Correct Answer is A
Explanation
Choice A rationale
Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar.
Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.
Choice B rationale
Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.
Choice C rationale
Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.
Choice D rationale
This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.
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