A nurse is assessing a client who has a fluid volume deficit. The nurse should expect which of the following findings?
Decreased hemoglobin (Hgb)
Increased blood urea nitrogen (BUN)
Increased urine ketones
Decreased urine specific gravity
The Correct Answer is B
Choice A reason:
Decreased hemoglobin (Hgb) levels can be indicative of anemia or blood loss, but they are not typically associated with fluid volume deficit. In cases of fluid volume deficit, the Hgb concentration may actually appear elevated due to hemoconcentration as the plasma volume decreases.
Choice B reason:
Increased blood urea nitrogen (BUN) levels are expected in a fluid volume deficit because as the blood volume decreases, the concentration of solutes like urea can increase. This is often due to decreased renal perfusion and subsequent reduced renal function, leading to less urea being excreted through the kidneys.
Choice C reason:
Increased urine ketones are typically associated with diabetic ketoacidosis or starvation, not directly with fluid volume deficit. Ketones are produced when the body breaks down fats for energy, which is not a process directly related to fluid volume status.
Choice D reason:
Decreased urine specific gravity would not be expected in fluid volume deficit; in fact, one would expect the opposite. Specific gravity measures the kidney's ability to concentrate urine. In fluid volume deficit, the urine specific gravity would likely be increased as the body attempts to conserve water.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Generalized urticaria, or hives, is not a common side effect of radiation therapy for lung cancer. While skin reactions can occur, they are usually localized to the area being treated. Urticaria might be a sign of an allergic reaction, which would require immediate attention, but it is not typically associated with radiation therapy¹.
Choice B reason:
Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the radiation field includes salivary glands. For lung cancer patients, if the radiation field is near the neck or upper chest, it could potentially affect salivary gland function. Monitoring for xerostomia is important because it can lead to difficulties in speaking, eating, and swallowing, and it increases the risk for dental problems².
Choice C reason:
While reviewing laboratory test results for low hemoglobin is an important part of nursing care, it is not specific to radiation therapy for lung cancer. Low hemoglobin could be related to the cancer itself or a side effect of other treatments like chemotherapy. It is important to monitor, but not the primary action related to radiation therapy³.
Choice D reason:
Observing for signs of infection is a general nursing responsibility for all patients, not specific to those receiving radiation therapy for lung cancer. However, if the patient's immune system is compromised due to the cancer or other treatments, vigilance for infection is heightened.
Correct Answer is C
Explanation
Choice A reason:
The statement "HIPAA is a federal law, not a state law" is correct. HIPAA is indeed a federal law that provides national standards to protect the privacy of personal health information.
Choice B reason:
The statement "HIPAA established regulations for individually identifiable health information in verbal, electronic, or written form" is also correct. HIPAA does regulate how individually identifiable health information should be protected and handled across various forms of communication.
Choice C reason:
The statement "Information about a client can be disclosed to family members at any time" indicates a need for further teaching. Under HIPAA, protected health information can only be disclosed to family members under certain conditions, such as when the patient has given permission or when it is directly relevant to the family member's involvement in the patient's care.
Choice D reason:
The statement "A client's address would be an example of personally identifiable information" is correct. Under HIPAA, a client's address is considered personally identifiable information, which is protected and cannot be disclosed without proper authorization.
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