A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

Urine specific gravity 1.015

Hematocrit 42%

Urine pH 6.5

BUN 5 mg/dL

Answer and Explanation

The Correct Answer is D

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

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Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

A. Stand facing the center of the bed at the client's side. B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot C. Keep knees and hips straight while bending at the waist toward the client D. Encourage the client to keep their legs straight and remain still.

Correct Answer is B

Explanation

A: Standing facing the center of the bed at the client's side is not the most stable position for moving a client, as it does not provide a wide base of support.
B: Placing feet apart with one foot in front of the other provides a wide base of support and allows the nurse to use their body weight to assist in the movement, making this the correct action.
C: Keeping knees and hips straight while bending at the waist toward the client can lead to back strain and does not utilize the stronger leg muscles, making it an incorrect action.
D: Encouraging the client to keep their legs straight and remain still may be helpful, but it does not directly involve the nurse's actions in moving the client, so it is not the correct answer to this question.

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A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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