A nurse is evaluating the laboratory findings of a client who has wound dehiscence following abdominal surgery. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Potassium 3.5 mEq/L

Sodium 145 mEq/L

Hematocrit 53%

HbA1c 5%

Answer and Explanation

The Correct Answer is C

Choice A reason: Potassium 3.5 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 3.5 to 5.0 mEq/L. Potassium is an electrolyte that regulates nerve and muscle function, acid-base balance, and fluid balance. Potassium level can be affected by various factors, such as diet, medication, kidney function, and dehydration.

Choice B reason: Sodium 145 mEq/L is not a finding that indicates fluid volume deficit because it is within the normal range, which is 136 to 145 mEq/L. Sodium is an electrolyte that regulates blood pressure, blood volume, and fluid balance. Sodium level can be affected by various factors, such as diet, medication, kidney function, and fluid loss.

Choice C reason: Hematocrit 53% is a finding that indicates fluid volume deficit because it is above the normal range, which is 38 to 50% for men and 34 to 46% for women. Hematocrit is the percentage of red blood cells in the total blood volume. Hematocrit level can increase due to dehydration, which causes hemoconcentration or increased blood viscosity.

Choice D reason: HbA1c 5% is not a finding that indicates fluid volume deficit because it is within the normal range, which is less than 5.7%. HbA1c is the percentage of hemoglobin that is attached to glucose. HbA1c level reflects the average blood glucose level over the past two to three months. HbA1c level can be affected by various factors, such as diabetes, anemia, and medication.

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Correct Answer is A

Explanation

Choice A reason: Flushing the tubing with water every 4 hours can prevent the tubing from clogging by clearing any residual formula or medication from the lumen.

Choice B reason: Replacing the bag and tubing every 24 hours can prevent bacterial contamination, but it does not prevent the tubing from clogging.

Choice C reason: Administering the feeding by gravity drip can cause overfeeding, aspiration, or diarrhea, but it does not prevent the tubing from clogging.

Choice D reason: Heating the formula prior to infusion can cause bacterial growth, nutrient loss, or burns, but it does not prevent the tubing from clogging.

A. Consume ten percent of total calories from saturated fat. B. Consume foods that are high in calcium. C. Increase intake of refined carbohydrates. D. Limit sodium intake to 3,200 milligrams per day.

Correct Answer is B

Explanation

Choice A reason: Consume ten percent of total calories from saturated fat is not a correct instruction for the DASH diet. The DASH diet recommends limiting saturated fat intake to less than six percent of total calories, as saturated fat can raise blood cholesterol and increase the risk of heart disease.

Choice B reason: Consume foods that are high in calcium is a correct instruction for the DASH diet. The DASH diet emphasizes eating foods that are rich in calcium, such as low-fat dairy products, leafy green vegetables, and fortified cereals. Calcium helps regulate blood pressure and prevent osteoporosis.

Choice C reason: Increase intake of refined carbohydrates is not a correct instruction for the DASH diet. The DASH diet advises reducing intake of refined carbohydrates, such as white bread, white rice, and sweets. Refined carbohydrates can increase blood sugar and insulin levels and contribute to obesity and diabetes.

Choice D reason: Limit sodium intake to 3,200 milligrams per day is not a correct instruction for the DASH diet. The DASH diet recommends limiting sodium intake to less than 2,300 milligrams per day, or even lower to 1,500 milligrams per day for some people. Sodium can increase blood pressure and fluid retention and damage the kidneys and blood vessels.

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A nurse is evaluating the laboratory findings of a client who has wound dehiscence following abdominal surgery. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Nursing Test Bank

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