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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Serum glucose of 118 mg/dL: This value is slightly above the normal range but not critically elevated; it does not typically require immediate notification to the surgeon.
B. Blood urea nitrogen (BUN) of 16 mg/dL: This BUN level is within the normal range and does not suggest an immediate concern for surgical risk.
C. Serum sodium of 130 mEq/L: A serum sodium level of 130 mEq/L indicates hyponatremia, which can lead to serious complications including neurological symptoms and should be addressed prior to surgery.
D. Serum potassium of 3.9 mEq/L: This level is within the normal range and does not require immediate action related to surgery.
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