The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Respiratory rate 24/min

Blood pressure 138/86 mm Hg

Total urinary output 700 mL in 24 hours

Weight loss of 4 lb in 24 hours

Answer and Explanation

The Correct Answer is D

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

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Correct Answer is D

Explanation

A. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.

A. Crush the medication and administer it through the tube B. Provide the medication orally for the client to swallow C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration D. Dissolve the medication in water and administer it through the tube

Correct Answer is C

Explanation

A. Crush the medication and administer it through the tube: Crushing sustained-release medications can disrupt their intended release mechanism, leading to potential overdose or ineffective treatment.
B. Provide the medication orally for the client to swallow: This option is not suitable since the client has a gastrostomy tube, and oral administration is not appropriate.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach, as an elixir form of the medication would be appropriate for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets can compromise their intended release mechanism, which may lead to complications.

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The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

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Naxlex Comprehensive Predictor Exams

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