A nurse is feeding a client who has heart failure. Which of the following findings indicates that the client is gaining fluid volume excess?
Creatinine 1.3 mg/dL
BNP 300 pg/mL
Potassium 3.5 mEq/L
Sodium 140 mEq/L
The Correct Answer is B
Choice A reason: Creatinine 1.3 mg/dL is slightly elevated, but it does not indicate fluid volume excess. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. High creatinine levels can indicate kidney damage or impaired renal function.
Choice B reason: BNP 300 pg/mL is high and indicates fluid volume excess. BNP stands for brain natriuretic peptide, which is a hormone released by the heart when it is stretched by increased blood volume or pressure. High BNP levels can indicate heart failure or fluid overload.
Choice C reason: Potassium 3.5 mEq/L is within the normal range (3.5-5.0), and it does not indicate fluid volume excess. Potassium is an electrolyte that helps regulate nerve and muscle function, especially the heart. Low or high potassium levels can cause cardiac arrhythmias, muscle weakness, or paralysis.
Choice D reason: Sodium 140 mEq/L is within the normal range (135-145), and it does not indicate fluid volume excess. Sodium is an electrolyte that helps maintain fluid balance, blood pressure, and nerve impulses. Low or high sodium levels can cause confusion, seizures, or coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Dietary restrictions will not eventually allow the intake of gluten to resume. Gluten is a protein found in wheat, barley, rye, and some oats. It causes damage to the small intestine in people with celiac disease. The only treatment for celiac disease is a lifelong gluten-free diet.
Choice B reason: This condition may cause secondary lactose intolerance. Lactose is a sugar found in milk and dairy products. It is broken down by an enzyme called lactase in the small intestine. People with celiac disease may have reduced levels of lactase due to the damage to the small intestine caused by gluten. This can lead to lactose intolerance, which is the inability to digest lactose properly. Symptoms of lactose intolerance include bloating, gas, diarrhea, and abdominal pain after consuming dairy products.
Choice C reason: Nutritional therapy for this condition does not include limiting proteins and calories. People with celiac disease need adequate amounts of proteins and calories to maintain their health and prevent malnutrition. They also need to ensure that they get enough vitamins, minerals, and fiber from gluten-free sources.
Choice D reason: A normal diet cannot resume after a period of remission. Celiac disease is a chronic autoimmune disorder that does not have a cure. Even if the symptoms improve or disappear, the damage to the small intestine can still occur if gluten is consumed. Therefore, a strict gluten-free diet must be followed for life.
Correct Answer is B
Explanation
Choice A reason: Feedings should not be accompanied by nonnutritive sucking. Nonnutritive sucking is the act of sucking on a pacifier, finger, or other object without getting any nutrition. Nonnutritive sucking can interfere with the establishment of breastfeeding, cause nipple confusion, and reduce milk supply.
Choice B reason: Feedings should be on demand. On demand feeding means feeding the newborn whenever they show signs of hunger, such as rooting, sucking, or crying. On demand feeding helps the newborn regulate their appetite, meet their nutritional needs, and bond with their caregiver.
Choice C reason: Feedings should not begin within 1 hr after birth. This instruction is applicable for breastfeeding, not bottle feeding. Breastfeeding should begin within 1 hr after birth to initiate milk production, stimulate uterine contractions, and transfer colostrum to the newborn. Bottle feeding can be delayed until the newborn is stable and alert.
Choice D reason: Feedings may not occur in clusters. Cluster feeding means feeding the newborn more frequently and for longer periods of time during certain times of the day or night. Cluster feeding is common in breastfed newborns, especially during growth spurts or developmental leaps. Bottle fed newborns may not exhibit cluster feeding, as they tend to have more consistent and predictable feeding patterns.
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