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 A
Explanation
Choice A reason: Alternating the first breast that is offered to the baby with each feeding can help ensure equal stimulation and drainage of both breasts, and prevent engorgement, mastitis, or milk supply problems.
Choice B reason: Storing breastmilk in the refrigerator up to 48 hours is not recommended, as it can reduce the quality and quantity of antibodies and nutrients in the milk. The optimal storage time for breastmilk in the refrigerator is up to 24 hours.
Choice C reason: Nursing the baby once every 4 hours is not sufficient, as it can lead to insufficient milk intake, dehydration, weight loss, or jaundice in the baby. The baby should be nursed on demand, or at least every 2 to 3 hours during the day and every 4 hours at night.
Choice D reason: Offering the baby water between feedings is not necessary, as it can interfere with breastfeeding and cause water intoxication or electrolyte imbalance in the baby. Breastmilk provides enough hydration and nutrition for the baby.
Correct Answer is ["58"]
Explanation
Step 1: Convert the weight from kilograms to pounds. 70 kg × 2.2 lbs/kg = 154 lbs Result at each step = 154 lbs
Step 2: Convert the height from meters to inches. 1.1 m × 39.37 inches/m = 43.307 inches Result at each step = 43.307 inches
Step 3: Convert the height from inches to feet. 43.307 inches ÷ 12 inches/foot = 3.609 feet Result at each step = 3.609 feet
Step 4: Calculate the BMI using the formula: BMI = weight (lbs) ÷ (height (inches))^2 × 703 BMI = 154 lbs ÷ (43.307 inches)^2 × 703 Result at each step = 154 lbs ÷ 1874.48 × 703 Result at each step = 0.0821 × 703 Result at each step = 57.7
Step 5: Round the BMI to the nearest whole number. Result at each step = 58
The client’s Body Mass Index (BMI) is 58.
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