The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Urine specific gravity 1.012.

+4 Pedal pulses.

Respiratory rate 20/minute.

Potassium level 3.8 mEq/L.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.

Choice B rationale

+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.

Choice C rationale

A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.

Choice D rationale

A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.

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Correct Answer is A

Explanation

Choice A rationale

Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.

Choice B rationale

While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.

Choice C rationale

A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.

Choice D rationale

The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.

A. The client is at increased risk for developing hypoglycemia. B. The client is demonstrating signs of insulin resistance. C. The client is demonstrating good control of blood glucose. D. The client is at increased risk for developing hyperglycemia.

Correct Answer is C

Explanation

Choice A rationale

The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.

Choice B rationale

Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.

Choice C rationale

Choice D rationale

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The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

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