The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

hypovolemic shock.

hemodilution.

excess fluid volume.

deficient fluid volume.

Answer and Explanation

The Correct Answer is C

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

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

Explanation

A. Reading back the calcium level result to the lab technician: Reading back results to the lab technician is a good practice to ensure accurate communication. The nurse verifies that they have received the correct information and confirms the accuracy of the result.

B. Document the time the call was received & the lab technician's name and date of birth. This was not selected because while documenting the time of the call and the lab technician's information may be useful for record-keeping purposes, it is not directly related to the immediate management of the client's low calcium level. Therefore, it is not essential to the immediate actions required in response to the lab result.

C. Reporting the elevated calcium level to the client's physician: An abnormally low calcium level (hypocalcemia) of 6.3 mg/dL requires prompt notification to the client's physician for further evaluation and intervention.

D. Confirming the client's full name, date of birth, & medical record number with the lab technician: Verifying the client's identity and medical record number ensures that the lab results are correctly matched to the right patient, minimizing the risk of errors in patient care.

E. Documenting the low calcium level in the client's electronic medical record: Documenting the calcium level in the client's electronic medical record ensures that the result is recorded for future reference and continuity of care. Accurate documentation is essential for tracking the client's health status and treatment outcomes.

A. Multiple lesions on dorsal aspect of feet probably due to elder abuse B. Four burned areas noted on plantar area of each foot C. Several partially healed lesions on bottom of left foot, looks like cigarette burns D. Four round, 2 cm in diameter lesions on plantar aspect of right foot

Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

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Naxlex Comprehensive Predictor Exams

A lab technician calls to tell the nurse that their client's calcium level is 6.3 mg/dL. How will the nurse proceed with this information? (SELECT ALL THAT APPLY)

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

Explanation

What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Correct Answer is D

Explanation

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