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

Concentrated hemoglobin and hematocrit levels

Distended neck veins

Decreased urine output

Poor skin turgor

Answer and Explanation

The Correct Answer is B

Choice A: Concentrated hemoglobin and hematocrit levels are not a sign of ﬂuid volume overload, but rather of ﬂuid volume deficit. This is a condition that occurs when the body loses more ﬂuid than it gains. This can happen in patients who have excessive bleeding, vomiting, diarrhea, or diaphoresis. Concentrated hemoglobin and hematocrit levels indicate hemoconcentration, which is an increase in the ratio of blood cells to plasma.

Choice B: Distended neck veins are a sign of ﬂuid volume overload, because this condition occurs when the body retains more ﬂuid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive ﬂuid intake. Distended neck veins indicate increased central venous pressure, which is a measure of the pressure in the right atrium of the heart.

Choice C: Decreased urine output is not a sign of ﬂuid volume overload, but rather of oliguria or anuria. These are conditions that occur when the urine output is less than 400 mL or 50 mL per day, respectively. These can happen in patients who have acute or chronic kidney injury, urinary obstruction, or shock. Decreased urine output indicates impaired renal function and decreased glomerular filtration rate.

Choice D: Poor skin turgor is not a sign of ﬂuid volume overload, but rather of dehydration. This is a condition that occurs when the body loses more water than it gains. This can happen in patients who have fever, diabetes insipidus, or hyperglycemia. Poor skin turgor indicates decreased skin elasticity and delayed return to normal shape after being pinched.

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Correct Answer is D

Explanation

Choice A: 18 mg/dL is incorrect because it is within the normal range of BUN, which is 7 to 20 mg/dL. BUN stands for blood urea nitrogen, which is a measure of the amount of nitrogen in the blood that comes from urea, a waste product of protein metabolism. BUN can reﬂect the kidney function and hydration status of the client.

Choice B: 10 mg/dL is incorrect because it is also within the normal range of BUN. A low BUN level can indicate liver problems, malnutrition, or overhydration.

Choice C: 13 mg/dL is incorrect because it is also within the normal range of BUN. A normal BUN level does not necessarily rule out dehydration, as other factors such as diet, medications, and blood loss can aﬀect the BUN level.

Choice D: 25 mg/dL is correct because it is above the normal range of BUN and indicates a high BUN level. A high BUN level can indicate dehydration, kidney failure, urinary tract obstruction, heart failure, or excessive protein intake. The nurse should report this value to the provider as it may require further evaluation and treatment.

A. Limit intake of canned soups. B. Choose botled salad dressings. C. Choose diet sodas over botled water. D. Replace processed meats with fresh meat products. E. Read labels on foods before eating.

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

Explanation

Choice A: Limit intake of canned soups is correct because canned soups are high in sodium and can increase blood pressure and ﬂuid retention. The nurse should advise the client to choose low-sodium or homemade soups instead.

Choice B: Choose botled salad dressings is incorrect because botled salad dressings are also high in sodium and can have added sugars and fats. The nurse should advise the client to make their own salad dressings with vinegar, oil, herbs, and spices.

Choice C: Choose diet sodas over botled water is incorrect because diet sodas are not a healthy alternative to water. Diet sodas contain artificial sweeteners, caﬀeine, and phosphoric acid, which can aﬀect the body's pH balance and calcium absorption. The nurse should advise the client to drink plain water or ﬂavored water with natural ingredients.

Choice D: Replace processed meats with fresh meat products is correct because processed meats such as bacon, ham, sausage, and hot dogs are high in sodium and preservatives. The nurse should advise the client to choose fresh meat products such as chicken, turkey, fish, or lean beef.

Choice E: Read labels on foods before eating is correct because reading labels can help the client identify the sodium content and other ingredients in foods. The nurse should advise the client to look for foods that have less than 140 mg of sodium per serving and avoid foods that have salt, sodium, or monosodium glutamate (MSG) in the ingredient list.

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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

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Correct Answer is D

Explanation

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

Explanation

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