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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Raynaud’s disease is a condition that affects blood flow to the extremities, including the fingers and toes, in response to cold temperatures or stress. Wearing heavy-duty gloves during cold exposures can help to keep the hands warm and reduce the risk of a Raynaud’s attack.

Choice B rationale

While avoiding cold temperatures can help to prevent Raynaud’s attacks, it is not always practical or possible for individuals to refrain from going outdoors during the winter months.

Choice C rationale

Raising the hands above the head is not typically recommended to relieve spasms associated with Raynaud’s disease.

Choice D rationale

Using small rubber balls to exercise the hands and fingers daily may be beneficial for some individuals with Raynaud’s disease, but it is not typically the primary recommendation for managing this condition.

A. Fourth intercostal space, right sternal border B. Second intercostal space, right sternal border C. Fifth intercostal space, left midclavicular line D. Third intercostal space, left midclavicular line .

Correct Answer is C

Explanation

A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.

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The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with Raynaud’s disease is experiencing severe pain and spasms in the fingers and toes of their hands. What advice should the nurse include in the discharge instructions for this client?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?

Correct Answer is C

Explanation

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