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 D

Explanation

Choice A rationale

Testing the stool for occult blood is not typically necessary for a client taking an antibiotic that causes diarrhea. While antibiotics can cause changes in the gastrointestinal tract, they do not typically cause gastrointestinal bleeding.

Choice B rationale

Increasing roughage in the diet can help bulk up the stool and may help alleviate some cases of diarrhea. However, it’s not the primary recommendation for a client taking an antibiotic that causes diarrhea.

Choice C rationale

Requesting the physician for a different antibiotic if diarrhea persists can be an appropriate action. However, this is typically recommended after other strategies, such as adding probiotics to the diet, have been tried.

Choice D rationale

Adding yogurt to the diet is often recommended for clients taking an antibiotic that causes diarrhea. Yogurt contains probiotics, which can help restore the balance of good bacteria in the gut and alleviate diarrhea.

A. Discuss the need for the client to lose weight. B. Invite the client’s family to participate in the program. C. Demonstrate how to check glucose using capillary blood glucose monitoring. D. Assess the client’s perception of what it means to live with diabetes.

Correct Answer is D

Explanation

Choice A rationale

While discussing the need for weight loss can be an important part of managing Type 2 diabetes, it should not necessarily be the initial step when developing an educational plan. Weight loss can help improve blood glucose control, but it’s just one aspect of a comprehensive diabetes management plan15.

Choice B rationale

Inviting the client’s family to participate in the program can be beneficial, as it can provide additional support for the client. However, the initial step in developing an educational plan should focus on the client’s understanding and perception of their diagnosis15.

Choice C rationale

Demonstrating how to check glucose using capillary blood glucose monitoring is an important skill for managing Type 2 diabetes. However, before teaching this skill, it’s important to assess the client’s understanding and readiness to learn15.

Choice D rationale

Assessing the client’s perception of what it means to live with diabetes should be the initial step when developing an educational plan. Understanding the client’s perspective can help tailor the education to meet their needs and improve their ability to manage their diabetes15.

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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

The nurse is aware that a client taking an antibiotic that causes diarrhea should be taught about:

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client has recently been diagnosed with Type 2 diabetes. What should be the nurse’s initial step when developing an educational plan?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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