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 ["B","E"]

Explanation

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

A. responsibility. B. confidentiality. C. social justice. D. advocacy

Correct Answer is D

Explanation

A. Responsibility: Responsibility refers to the duty or obligation to fulfill one's role or tasks appropriately. While advocating for the client may be considered a responsibility of the nurse, the specific action described in the scenario—calling the insurance company to strongly explain the client's need for rehabilitation—is more accurately categorized as advocacy.

B. Confidentiality: Confidentiality pertains to protecting the privacy and confidentiality of patient information. The scenario does not involve the disclosure of confidential information but rather advocating for the client's needs regarding their rehabilitation placement.

C. Social justice: Social justice involves promoting fairness, equality, and equitable access to resources and opportunities for all members of society. While advocating for the client may align with principles of social justice, the specific action described in the scenario—calling the insurance company to argue for the client's rehabilitation placement—is more directly related to individual advocacy rather than addressing broader societal inequalities.

D. Advocacy: Advocacy refers to actively supporting and speaking up for the rights, needs, and interests of others. In this scenario, the nurse advocates for the elderly client by calling the insurance company to strongly explain why the client needs to go to a rehabilitation facility despite the facility's refusal. This action demonstrates the nurse's commitment to ensuring the client receives appropriate care and support.

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 examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

Correct Answer is D

Explanation

When working with clients of any age, the nurse keeps in mind that the key to mutually-satisfying, healthy sexual relationships between partners is most often:

The nurse is caring for a client who trips and falls over a trash can left in the path to the bathroom. Which is part of an appropriate charting entry?

Nurse Z is extremely attentive to their client's emotional & spiritual needs. The nurse spends up to 45 minutes each day providing the psychosocial support. As a result, the nurse does not plan enough time to perform assessments or give medications on time. This nurse is liable for:

Which food item should the nurse instruct the patient to consume to prevent or treat constipation?

The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?

The nurse assesses a client admitted with a history of vomiting and diarrhea for 5 days. Which laboratory value validates the symptoms of the client?

The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)