Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)
Palpate the rate and volume of the pulse.
Check fingernails for the presence of clubbing.
Measure body weight at the same time daily
Observe the color and amount of urine
Compare muscle strength of both arms.
Correct Answer : A,C,D
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of fluid volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.
The other options are not correct because:
b. Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.
e. Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle weakness is not a specific sign of fluid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.
Correct Answer is ["B","C","E"]
Explanation
A) Incorrect- While hydration is important, this response doesn't directly address the client's question about the content and timing of meals.
B) Correct- Complex carbohydrates high in fiber content have a slower impact on blood glucose levels, promoting better glycemic control.
C) Correct- Bedtime snacks can be helpful to prevent nighttime hypoglycemia, but if heartburn develops, it may be necessary to modify the timing or content of the snack.
D) Incorrect- This response is not directly related to managing blood glucose levels or gestational diabetes.
E) Correct- Refined sugars can cause rapid spikes in blood glucose levels, so avoiding them helps maintain stable glycemic control.
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