A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Serum K+ 3.6 mEq/L

Urine specific gravity of 1.012

Respiratory rate 18

+4 Pedal Pulses

Answer and Explanation

The Correct Answer is D

A. Serum K+ 3.6 mEq/L: Serum potassium (K+) level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically validate fluid volume excess. Serum electrolyte levels can be affected by various factors, including hydration status, renal function, and medications. While hypokalemia (low potassium) may be associated with conditions such as diuretic use or excessive fluid loss, it is not a definitive indicator of fluid volume excess.

B. Urine specific gravity of 1.012: Urine specific gravity measures the concentration of solutes in the urine and can provide information about the client's hydration status. A specific gravity of 1.012 is within the normal range (typically 1.005 to 1.030), indicating that the urine is neither extremely concentrated nor dilute. While changes in urine specific gravity may suggest alterations in fluid balance, a single measurement alone may not be sufficient to validate the client's fluid status, especially in the context of fluid volume excess.

C. Respiratory rate 18: A respiratory rate of 18 breaths per minute falls within the normal range for adults (12-20 breaths per minute) and does not specifically indicate fluid volume excess. Changes in respiratory rate may occur in response to various factors, including respiratory, cardiovascular, or metabolic conditions, but it is not a direct indicator of fluid volume status.

D. +4 Pedal Pulses:

The presence of +4 pedal pulses indicates strong, bounding pulses in the feet. This finding suggests adequate perfusion to the peripheral extremities, which may indicate an appropriate fluid balance. In clients with fluid volume excess, maintaining adequate perfusion to peripheral tissues is essential to prevent complications such as peripheral edema and impaired tissue oxygenation. Strong pedal pulses suggest that perfusion to the lower extremities is not compromised due to hypovolemia or decreased cardiac output, which can be associated with fluid volume deficit.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. gender identity: Gender identity refers to how a person internally perceives and identifies their gender, which may be male, female, both, neither, or another gender identity. It is a deeply-held sense of being male, female, a blend of both genders (androgyny), or neither gender. Gender identity is an intrinsic aspect of a person's self-concept and may or may not align with the sex assigned at birth.

B. sexual orientation: Sexual orientation refers to a person's romantic or sexual attraction to individuals of the same gender, different gender, or multiple genders. It is distinct from gender identity and encompasses identities such as heterosexual, homosexual, bisexual, pansexual, etc.

C. androgyny: Androgyny refers to a combination of masculine and feminine characteristics or qualities in a single individual. It is a term used to describe a gender expression that does not conform strictly to traditional gender roles or expectations. While related to gender expression, it is not synonymous with gender identity.

D. body image: Body image refers to a person's perception, thoughts, and feelings about their own body's appearance, size, shape, and function. It includes attitudes towards physical attributes, such as weight, height, and physical features, and can influence self-esteem and overall well-being. Body image is related to, but distinct from, gender identity, which focuses specifically on one's internal sense of gender.

A. frequent enuresis. B. urinary frequency. C. urinary urgency. D. urge incontinence.

Correct Answer is C

Explanation

A. frequent enuresis: Frequent enuresis refers to the involuntary loss of urine during the day or night, often associated with bedwetting. It does not specifically describe the sudden, compelling need to urinate described by the client.

B. urinary frequency: Urinary frequency is the need to urinate more often than usual, which may or may not be associated with urgency. It does not fully capture the sudden, urgent need to urinate described by the client.

C. urinary urgency: Urinary urgency is the sudden, compelling need to urinate that cannot be delayed. This aligns with the client's description of feeling like they have to go immediately and cannot wait. Therefore, this is the most appropriate choice.

D. urge incontinence: Urge incontinence involves the involuntary loss of urine associated with a sudden, strong desire to urinate. While similar to urinary urgency, it specifically refers to the leakage of urine that can occur due to the inability to reach the toilet in time after feeling the urge to urinate. However, the client's statement does not indicate actual urine leakage, making this option less appropriate than urinary urgency.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that how a client feels on the inside about being male, female, both or neither is known as:

Correct Answer is A

Explanation

The client tells the nurse. "The need to urinate comes on me all of a sudden, and it feels as though I have to go immediately-that I can't wait." The nurse charts that the client is experiencing:

Correct Answer is C

Explanation

A lab technician calls to tell the nurse that their client's calcium level is 6.3 mg/dL. How will the nurse proceed with this information? (SELECT ALL THAT APPLY)

A nurse is providing instructions to a client receiving a diuretic that causes potassium loss. Which foods rich in potassium should the nurse recommend? (SELECT ALL THAT APPLY)

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

The nurse teaches the client that fiber provides the bulk in the stools to allow for easier defecation. The nurse recognizes that teaching is effective when the client's menu choices include more:

Which position would be appropriate for the nurse to perform an abdominal assessment?

A 35-year-old male client shares with the nurse that he has always thought of himself as being female. The client feels anxious, embarrassed and socially isolated. How should the nurse respond to this client?

The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?