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 A

Explanation

Urine specific gravity 1.020.

Choice A rationale:

Urine specific gravity is a measure of urine concentration, indicating the ability of the kidneys to concentrate or dilute urine. A specific gravity of 1.020 falls within the normal range (typically 1.010 to 1.030). An appropriate specific gravity indicates that the client's kidneys are responding well to the IV fluids, maintaining adequate urine output and concentration.

Choice B rationale:

Potassium level of 5.2 mEq/L is above the normal range of 3.5 to 5 mEq/L. However, this value does not specifically indicate whether the client is responding effectively to the IV fluids for dehydration.

Choice C rationale:

Hct (Hematocrit) of 6296 is not a valid measurement; it appears to be a typographical error or an incomplete value. Therefore, it cannot be used to assess the client's response to treatment.

Choice D rationale:

Sodium level of 165 mEq/L is elevated beyond the normal range of 136 to 145 mEq/L. However, this value does not provide information about the client's response to IV fluids for dehydration.

A. Contraction of the facial muscles. B. Complaints of fingers tingling. C. Carpal spasm with blood pressure measurement. D. Asked when the foot numbness would go away.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

The nurse considered contraction of facial muscles as a finding of hypocalcemia because it is associated with Chvostek's sign, which indicates neuromuscular irritability due to low calcium levels.

Choice B rationale:

Complaints of fingers tingling are indicative of hypocalcemia since tingling sensations (paresthesias) in the extremities can result from decreased calcium levels affecting nerve function.

Choice C rationale:

Carpal spasm with blood pressure measurement is known as Trousseau's sign and is associated with hypocalcemia. When the blood pressure cuff is inflated above systolic pressure, it can cause tetany in the hand if the calcium levels are low.

Choice D rationale:

Asking when foot numbness would go away does not directly relate to hypocalcemia or its symptoms. It is not a finding used to come to the conclusion of hypocalcemia in this scenario.

Choice E rationale:

The heart rate being 88 and regular does not directly indicate hypocalcemia. While hypocalcemia can lead to cardiac arrhythmias, a heart rate of 88 and regular is within the normal range and not a specific finding for hypocalcemia.

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

Correct Answer is A

Explanation

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PacO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L.

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The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

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