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 D

Explanation

Choice D rationale

Hyperosmolar Hyperglycemic Syndrome (HHS) is a serious complication of diabetes that occurs when blood sugar levels are extremely high. The primary treatment for HHS is intravenous fluids and insulin. Specifically, 0.9% saline solution IV is often used initially to restore volume and correct severe dehydration.

Choice A rationale

Administration of Glucagon is not the primary treatment for HHS. Glucagon is a hormone that raises blood glucose levels and would not be beneficial in a situation where blood glucose is already extremely high.

Choice B rationale

Dextrose 50% is a concentrated glucose solution and would not be appropriate in the treatment of HHS, where blood glucose levels are already dangerously high.

Choice C rationale

While IV fluids are a crucial part of the treatment for HHS, 0.45% Normal Saline (also known as half-normal saline) is a hypotonic solution and is not typically the first choice for fluid resuscitation in HHS. The preferred initial fluid is often 0.9% saline (normal saline), which is isotonic.

A. Administer the PRN antianxiety medication. B. Call the rapid response team. C. Increase the intravenous infusion rate. D. Prepare for mechanical ventilation.

Correct Answer is B

Explanation

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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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

Correct Answer is D

Explanation

Choice D rationale

Choice A rationale

Choice B rationale

Choice C rationale

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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