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 A

Explanation

A. Warfarin (Coumadin): This is the correct choice. Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. The surgeon needs to be notified to consider holding the medication and to adjust the surgical plan if necessary.
B. Gabapentin (Neurontin): While important for pain management, it does not significantly impact surgical procedures or bleeding risk.
C. Xanax (Alprazolam): This medication is a benzodiazepine used for anxiety, which might be relevant for preoperative anxiety but does not require immediate notification of the surgeon.
D. Atenolol (Tenormin): This beta-blocker is used for hypertension and heart conditions but does not require immediate notification of the surgeon unless there are specific cardiac concerns related to surgery.

A. The client who takes medications for occasional anxiety B. The client admitted with a mild pleural effusion C. The client who has had diarrhea for the past 48 hours D. The client admitted with an acute renal injury E. The client admitted for treatment of asthmatic bronchitis

Correct Answer is ["C","D"]

Explanation

A. The client who takes medications for occasional anxiety: Anxiety medications are not typically associated with metabolic acidosis.
B. The client admitted with a mild pleural effusion: A mild pleural effusion is more related to fluid accumulation and respiratory issues rather than metabolic acidosis.
C. The client who has had diarrhea for the past 48 hours: Prolonged diarrhea can lead to loss of bicarbonate, resulting in metabolic acidosis.
D. The client admitted with an acute renal injury: Acute renal injury impairs the kidneys' ability to excrete acids and can lead to metabolic acidosis.
E. The client admitted for treatment of asthmatic bronchitis: Asthmatic bronchitis typically involves respiratory issues rather than metabolic acidosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["C","D"]

Explanation

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