A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

Pyuria

Weight loss

Jugular vein distention

Muscle contractions

Answer and Explanation

The Correct Answer is C

Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.

Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.

Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.

Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.

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Correct Answer is D

Explanation

Choice A reason: H2-receptor antagonist and two antibiotics is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists are drugs that block the action of histamine on the stomach cells, reducing the production of acid. They are used to treat peptic ulcers, but they are not effective against H. pylori bacteria. The "triple therapy" regimen requires an antibiotic to kill the bacteria, and a proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice B reason: Two proton-pump inhibitors and an antibiotic is not the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, but they are not enough to eradicate H. pylori bacteria. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice C reason: H2-receptor antagonist, proton pump inhibitor, and an antibiotic is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists and proton-pump inhibitors have similar effects on the stomach acid, but they work in different ways. They are both used to treat peptic ulcers, but they are not necessary to use together. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice D reason: Proton-pump inhibitor and two antibiotics is the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, and they also enhance the effectiveness of the antibiotics. The "triple therapy" regimen requires two antibiotics to kill the H. pylori bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing. The most common antibiotics used are amoxicillin, clarithromycin, and metronidazole.

A. Client who weighs 28% above ideal body weight B. Client who has a waist circumference of 81.3 cm (32 in) C. Client who has a BMI of 28 D. Client who has a body fat of 22%

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because weighing 28% above ideal body weight is a sign of obesity. Ideal body weight is an estimate of the weight that corresponds to the lowest mortality for a given height and gender. Obesity is defined as having a body weight that is 20% or more above ideal body weight.

Choice B reason: This is not the correct answer because having a waist circumference of 81.3 cm (32 in) is not a manifestation of obesity. Waist circumference is a measure of abdominal fat, which is associated with increased health risks. However, the cut-off point for waist circumference varies by gender and ethnicity. For women, a waist circumference of more than 88 cm (35 in) is considered high.

Choice C reason: This is not the correct answer because having a BMI of 28 is not a manifestation of obesity. BMI is a measure of body mass index, which is calculated by dividing weight in kilograms by height in meters squared. BMI is used to classify weight status and health risks. For adults, a BMI of 18.5 to 24.9 is considered normal, 25 to 29.9 is considered overweight, and 30 or more is considered obese.

Choice D reason: This is not the correct answer because having a body fat of 22% is not a manifestation of obesity. Body fat is a measure of the percentage of fat in the body, which is determined by various methods such as skinfold thickness, bioelectrical impedance, or underwater weighing. Body fat is influenced by age, gender, and physical activity. For women, a body fat of 21 to 33% is considered normal, 33 to 39% is considered high, and more than 39% is considered very high.

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A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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