The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

adventitious breath sounds

weak pulse

hypotension

poor skin turgor

Answer and Explanation

The Correct Answer is A

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.

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Free Nursing Study Resources

Correct Answer is ["15"]

Explanation

To calculate the dose of phenytoin suspension, the nurse should use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL) x Volume (mL)

Plugging in the values from the question, we get:

Dose (mL) = 75 mg / (25 mg/5 mL) x 5 mL

Dose (mL) = 15 mL

Therefore, the nurse should administer 15 mL of phenytoin suspension to the patient

Correct Answer is ["10"]

Explanation

To calculate the dose of valproic acid oral solution, the nurse should use the following formula:

Dose (mL) = Ordered dose (mg) / Concentration (mg/mL) x Volume (mL)

Plugging in the values from the question, we get:

Dose (mL) = 500 mg / (250 mg / 5 mL) x 5 mL

Simplifying, we get:

Dose (mL) = 500 mg / 50 mg x 5 mL

Dose (mL) = 10 mL

Therefore, the nurse should administer 10 of valproic acid oral solution to the patient.

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The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phenytoin 75 mg PO. Available is phenytoin suspension 25 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["15"]

Explanation

A nurse is preparing to administer valproic acid 500 mg PO. Available is valproic acid oral solution 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

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