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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe.

Correct Answer is C

Explanation

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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