Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Heart rate 99 beats/minute

Dark, yellow urine

Urinated 30 mL

Temperature 101° F (38.3° C)

Answer and Explanation

Correct Answer : A,B,C

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. Eggs. B. Broccoli. C. Spinach. D. Dairy products. E. Bananas.

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

Explanation

A. Eggs are not a significant source of vitamin K. Foods rich in vitamin K are primarily green leafy vegetables and certain other plant-based foods.
B. Broccoli is a good source of vitamin K. It is rich in this nutrient, which plays a crucial role in blood clotting and bone health.
C. Spinach is an excellent source of vitamin K. It is one of the top leafy greens that provide this vitamin and supports various bodily functions.
D. Dairy products do not contain significant amounts of vitamin K. They are more associated with calcium and vitamin D.
E. Bananas are not a notable source of vitamin K. They are rich in potassium but not in vitamin K.

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Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

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Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.

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

Explanation

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Exhibits

Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings.

Which three of the following client findings indicate that the client may still have a fluid volume deficit?