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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Choice A rationale:
Target conditions are not mentioned in the sentence, and there is no context to suggest their relevance to the client's situation.
Choice B rationale:
Hyperactive reflexes are not commonly associated with a urinary tract infection or the prescribed medications.
Choice C rationale:
The client with a urinary tract infection and the medications mentioned (Furosemide and Trimethoprim/sulfamethoxazole) are at an increased risk of hypokalemia (low potassium levels) due to Furosemide's diuretic effect, fluid volume deficit (dehydration) from the infection, and hypertension (high blood pressure) as a potential side effect of Trimethoprim/sulfamethoxazole.
Choice D rationale:
Urinary retention is not expected in a client with a urinary tract infection; it is more commonly associated with urinary obstruction or other urinary conditions unrelated to an infection.
Correct Answer is B
Explanation
Choice A rationale:
A phosphorus level of 4.5 mEq/L falls within the normal range, which is typically between 2.5 to 4.5 mEq/L. Although it's essential to monitor phosphorus levels, it is not the priority finding in this scenario.
Choice B rationale:
A potassium level of 2.9 mEq/L is the priority finding. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias and muscle weakness. Immediate intervention is necessary to address the potassium imbalance.
Choice C rationale:
A calcium level of 8.2 mg/dL falls within the normal range (typically 8.5 to 10.2 mg/dL). While calcium levels are essential to monitor, they do not take precedence over the critically low potassium level in this situation.
Choice D rationale:
A sodium level of 145 mEq/L falls within the normal range, which is usually around 135 to 145 mEq/L. Although monitoring sodium levels is important, it is not the priority finding when compared to the critically low potassium level.
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