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 overload, 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 C

Explanation

A) Incorrect- reapplying a sterile non-adhesive dressing is not enough to address the infection.

The nurse should also clean the wound, apply topical antimicrobial agents, and change the dressing regularly.
B) Incorrect- limiting visitors to immediate family only is not a sufficient infection control measure. The nurse should also use standard precautions, such as wearing gloves, gowns, masks,
and eye protection, and educate the visitors about hand hygiene and proper disposal of contaminated items.
C) Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response.
D) Incorrect- requesting a nutrition consult is not a priority action. While nutrition is important for wound healing, it does not directly affect the infection. The nurse should first administer antibiotics and then assess the client's nutritional status and needs.

A. The ﬂowmeter shows 1 liter of oxygen being delivered. B. There is no humidifier attached to the delivery system. C. The client is lying in a supine position in the bed. D. The cannula is pressed snugly against the client's cheeks.

Correct Answer is A

Explanation

This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the ﬂowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.

The other options are not correct because:

B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.

C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not aﬀect the oxygen delivery or uptake.

D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen ﬂow or diﬀusion.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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