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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is a) PaCO2 50 mm Hg. This is because respiratory acidosis is a condition in which the lungs cannot remove enough carbon dioxide from the blood, resulting in a high level of PaCO2. The normal range of PaCO2 is 35 to 45 mm Hg.
Choice b) HCO3 30 mEq/L is incorrect because this is a normal value for bicarbonate, which is a buffer that helps maintain the acid-base balance in the blood. The normal range of HCO3 is 22 to 26 mEq/L.
Choice c) pH 7.45 is incorrect because this is a normal value for the acidity or alkalinity of the blood. The normal range of pH is 7.35 to 7.45. Respiratory acidosis causes a low pH, indicating acidemia.
Choice d) Potassium 3.3 mEq/L is incorrect because this is a low value for potassium, which is an electrolyte that helps regulate nerve and muscle function, fluid balance, and blood pressure. The normal range of potassium is 3.5 to 5.0 mEq/L. Respiratory acidosis can cause hyperkalemia, or high potassium levels, due to the shift of hydrogen ions into cells and potassium out of cells.
Correct Answer is B
Explanation
Choice A: Sodium level is not a reliable measure of fluid retention because it can be affected by other factors such as diet, medication, and dehydration. Sodium level does not reflect the amount of water in the body.
Choice B: Daily weight is the most reliable measure of fluid retention because it reflects the changes in total body water. A weight gain of more than 0.5 kg (1 lb) in a day or 1.5 kg (3 lb) in a week indicates fluid retention.
Choice C: Intake and output is not a reliable measure of fluid retention because it does not account for insensible losses such as sweating, breathing, and fever. Intake and output can also be inaccurate due to measurement errors or incomplete records.
Choice D: Tissue turgor is not a reliable measure of fluid retention because it can be influenced by age, skin elasticity, and hydration status. Tissue turgor does not indicate the amount of fluid in the intravascular space.
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