A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?
Edema
Oliguria
Hypotension
Hyperthemia
The Correct Answer is A
A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.
B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.
C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.
D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, are used to maintain fluid balance and are not ideal for treating hypernatremia. They do not correct the elevated sodium levels and might even contribute to fluid overload.
B) Total Parenteral Nutrition (TPN): TPN is a form of nutrition provided intravenously and is not specifically used to manage electrolyte imbalances like hypernatremia. It is used for clients who cannot eat or absorb nutrients through the gastrointestinal tract.
C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, are used to treat hyponatremia or other conditions requiring increased sodium concentration. They would exacerbate hypernatremia rather than treat it.
D) Hypotonic solution: Hypotonic solutions, such as 0.45% sodium chloride (half-normal saline) or dextrose 5% in water (D5W), are appropriate for treating hypernatremia. These solutions help dilute the excess sodium in the blood, reduce serum sodium levels, and facilitate a gradual correction of the imbalance.
Correct Answer is D
Explanation
A) Chadwick's sign: Chadwick's sign is related to pregnancy and refers to the bluish discoloration of the cervix and vaginal walls due to increased blood flow. It is not associated with calcium levels or postoperative thyroidectomy.
B) Murphy's sign: Murphy's sign is used to diagnose gallbladder inflammation or cholecystitis. It involves palpation of the right upper quadrant of the abdomen and is not related to calcium levels or thyroid surgery.
C) Babinski's sign: Babinski's sign is a neurological reflex test used to assess the presence of upper motor neuron lesions. It is not associated with calcium levels or postoperative thyroidectomy.
D) Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, where tapping on the facial nerve causes twitching of the facial muscles. With the client's calcium level of 3 mg/dL, which is significantly low, Chvostek's sign would likely be positive, indicating hypocalcemia.
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