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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice B rationale
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice C rationale
A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice D rationale
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.
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.
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