Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Neck veins are now distended in the sitting position.

Breath sounds can be heard in the right lower lung lobe.

Weight is unchanged from that obtained yesterday.

Nose and ears have a slightly yellow-tinged appearance.

Answer and Explanation

The Correct Answer is A

Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.

Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.

Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.

Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.

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Correct Answer is B

Explanation

Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.

Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.

Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.

Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.

A. Nonmaleficence. B. Fidelity. C. Beneficence. D. Veracity.

Correct Answer is D

Explanation

Choice A reason: Nonmaleficence ensures no harm but is secondary to veracity, which provides truthful information for consent. Truthfulness is critical, making this incorrect, as it’s not the primary ethical principle the nurse prioritizes when soliciting informed consent from a patient.

Choice B reason: Fidelity involves keeping promises but doesn’t directly ensure the patient receives accurate information for consent. Veracity is key, making this incorrect, as it’s less relevant than the nurse’s focus on truthfulness during the informed consent process.

Choice C reason: Beneficence promotes well-being but is less critical than veracity, which ensures informed decision-making. Truthful disclosure is primary, making this incorrect, as it’s secondary to the nurse’s ethical priority when obtaining informed consent from the patient.

Choice D reason: Veracity, or truthfulness, is the most important principle, ensuring the patient receives accurate information for informed consent. This aligns with ethical standards, making it the correct principle the nurse prioritizes to support autonomous decision-making during the consent process.

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Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which ethical principle is most important when soliciting informed consent from a patient?

Correct Answer is D

Explanation

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