Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Palpate the rate and volume of the pulse.

Check fingernails for the presence of clubbing.

Measure body weight at the same time daily.

Observe the color and amount of urine.

Compare muscle strength of both arms.

Answer and Explanation

Correct Answer : A,C,D

The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of ﬂuid volume excess. These actions can help detect changes in the cardiovascular, renal, and ﬂuid balance systems that may indicate ﬂuid overloads, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.

The other options are not correct because:

B. Checking fingernails for the presence of clubbing is not relevant for assessing ﬂuid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.

E. Comparing muscle strength of both arms is not relevant for assessing ﬂuid volume excess, as muscle weakness is not a specific sign of ﬂuid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.

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Correct Answer is B

Explanation

Rationale for A: Skipping a meal can lead to elevated blood glucose levels, but it typically would not result in ketoacidosis unless accompanied by insulin deficiency.

Rationale for B: Administering too much insulin would lead to hypoglycemia rather than ketoacidosis, as it would lower blood glucose levels and prevent the production of ketones.

Rationale for C: Illness, such as a cold and ear infection, can increase insulin resistance and metabolic stress, leading to elevated blood glucose levels and precipitating diabetic ketoacidosis.

Rationale for D: Eating an extra sandwich before gym class would generally increase blood glucose levels but would not directly lead to ketoacidosis unless there was inadequate insulin to manage the increased intake.

A. Establish a second IV site. B. Stop the normal saline infusion. C. Assess the IV for blood return. D. Discontinue the 24 gauge IV.

Correct Answer is B

Explanation

A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.

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Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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