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 C
Explanation
Choice A rationale
While it is true that warfarin’s effectiveness can be affected by vitamin K, found in green leafy vegetables, it is not necessary to completely omit these from the diet. Instead, maintaining a consistent intake of vitamin K can help keep INR levels stable.
Choice B rationale
Over-the-counter pain relief medications, especially those that are nonsteroidal anti- inflammatory drugs (NSAIDs), can increase the risk of bleeding when taken with warfarin. Therefore, this advice is not correct.
Choice C rationale
Regular laboratory tests, specifically the International Normalized Ratio (INR), are crucial when taking warfarin to monitor its effectiveness and adjust the dosage if necessary.
Choice D rationale
Using an electric razor can help prevent cuts and bleeding, which is important because warfarin is a blood thinner. However, this information is not as critical as obtaining regular laboratory tests.
Choice E rationale
Obtaining a medical alert bracelet can be beneficial for individuals taking warfarin, as it can alert healthcare professionals in an emergency situation about the individual’s use of a blood thinner. However, this information is not as critical as obtaining regular laboratory tests.
Correct Answer is B
Explanation
Choice A rationale
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
Choice B rationale
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice C rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice D rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.
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