A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

Distended neck veins.

Poor skin turgor.

Concentrated hemoglobin and hematocrit levels.

Decreased urine output.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.

Choice B rationale:

Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.

Choice C rationale:

Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.

Choice D rationale:

Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.

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Correct Answer is ["C","D","E"]

Explanation

The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.

Choice A rationale:

Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.

Choice B rationale:

Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.

Choice C rationale:

Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.

Choice D rationale:

Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.

Choice E rationale:

Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.

A. A client who has a phosphate of 5.7 mg/dL. B. A client who has a calcium of 9.8 mg/dL. C. A client who has a vitamin D of 25 ng/mL. D. A client who has a magnesium of 1.8 mEq/L.

Correct Answer is A

Explanation

Choice A rationale:

The client with a phosphate level of 5.7 mg/dL likely has a manifestation of hypoparathyroidism. Hypoparathyroidism leads to decreased parathyroid hormone (PTH) secretion, which causes increased renal phosphate reabsorption, leading to elevated phosphate levels in the blood.

Choice B rationale:

A calcium level of 9.8 mg/dL is within the normal range (8.5-10.2 mg/dL) and does not indicate hypoparathyroidism.

Choice C rationale:

A vitamin D level of 25 ng/mL is within the normal range (30-100 ng/mL) and does not suggest hypoparathyroidism.

Choice D rationale:

A magnesium level of 1.8 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not directly indicate hypoparathyroidism.

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A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

Correct Answer is A

Explanation

A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.

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