The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate that the patient is experiencing this complication and should be reported? (Select all that apply.)
Skin turgor good and capillary refill less than three seconds
Decreased urine output and dry mucous membranes
Shortness of breath and crackles in lungs
Elevated blood pressure and edema
Correct Answer : C,D
Rationale:
A. Skin turgor and capillary refill within normal limits indicate adequate hydration, not fluid excess.
B. Decreased urine output and dry mucous membranes are signs of fluid volume deficit, not excess.
C. Shortness of breath and crackles in the lungs occur due to pulmonary congestion from fluid overload and should be reported.
D. Elevated blood pressure and edema are classic signs of fluid volume excess caused by increased circulating volume and fluid shift into tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A gastric aspirate pH of 7 is not consistent with normal gastric acidity (which is usually 1–4). A neutral pH may indicate that the NG tube is in the lungs or intestines. The nurse should anticipate a chest x-ray to verify placement before using the tube.
B. A pH of 7 is not expected for gastric contents and should not be accepted as normal.
C. Pulling back on the tube does not ensure correct placement and may still leave the tube malpositioned.
D. Advancing the tube without confirmation increases the risk of misplacement and potential complications.
Correct Answer is C
Explanation
Rationale:
A. The prescriber is responsible for writing a clear and legible order, but the nurse should have clarified before administering.
B. The pharmacist helps verify medication orders but does not administer the medication.
C. The nurse is ultimately responsible for ensuring the order is clear and safe before administration. Administering a drug without clarification makes the nurse accountable for the error.
D. Errors are not considered “no fault”; accountability and corrective action are necessary to protect patient safety.
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