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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.
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