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
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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Related Questions
Correct Answer is B
Explanation
A. Absence of the client's gag reflex: This finding is not typically related to spinal anesthesia complications. The gag reflex is more pertinent to general anesthesia and its effects on the brainstem.
B. The client has a respiratory rate of eight (8): This is the correct choice. A low respiratory rate (bradypnea) could indicate significant complications from spinal anesthesia, such as respiratory depression, especially if the anesthesia affects the muscles involved in respiration.
C. Loss of sensation at the 5th lumbar space: This could be a normal effect of spinal anesthesia if the level of anesthesia was intended to cover this area, but it does not necessarily indicate a complication.
D. The blood pressure is within 20% of the client's baseline: A slight change in blood pressure within this range is generally not considered a severe complication of spinal anesthesia. Significant hypotension or instability would be more concerning.
Correct Answer is D
Explanation
A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.
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