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.

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 C

Explanation

A. Discontinued medications do not provide actionable information for the receiving facility, as they are no longer relevant to the client's ongoing care. Including this information may lead to confusion about the current treatment plan.
B. Resolved health conditions are not a priority to communicate because they do not require further monitoring or intervention. Focus should be placed on active health concerns and ongoing care needs.
C. The frequency of vital sign collection is critical information for the receiving facility to maintain continuity of care and ensure appropriate monitoring of the client's condition. This detail helps guide the long-term care staff in managing the client’s ongoing health needs effectively.
D. Completed nursing interventions are not typically included in the transfer report as they have already been addressed and do not impact future care. The focus should remain on ongoing and future interventions required for the client.

A. Place the client's medication record on the bedside table while ambulating the client. B. Give a report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information.

Correct Answer is C

Explanation

A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.
B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.
C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.
D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.

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 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

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Correct Answer is C

Explanation

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

Correct Answer is C

Explanation

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

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.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of her behavior change?

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?