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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- While bedtime monitoring is important, the frequency described in this choice is not consistent with FSBG monitoring before meals.
B) Correct- Performing FSBG monitoring before each meal helps the client track her blood glucose levels before consuming food, allowing her to adjust her diet or insulin regimen if necessary.
C) Incorrect- Monitoring every two hours may be excessive and not necessary for managing gestational diabetes.
D) Incorrect- Monitoring during the night is important for glycemic control, but it doesn't specifically address the need to monitor before meals.
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
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