°4.ID: 8482500729A nurse is caring for a client who is being treated for congestiveheart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? Dyspnea1+ edema in the legsMoist crackles in the lower lobes of the lungsWeight loss of 4 lb in 24 hours Correct°Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreasedhematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved. ° ° Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving. ° ° Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 182, 183). St. Louis: Saunders. ° ° Level of Cognitive Ability: Evaluating ° ° Client Needs: Physiological Integrity ° ° Integrated Process: Nursing Process/Evaluation ° ° Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points. ° 5.ID: 8482493996A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding?
° ° Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that ST-segment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia. ° ° Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 184, 188). St. Louis: Saunders. ° ° Level of Cognitive Ability: Analyzing ° ° Client Needs: Physiological Integrity ° ° Integrated Process: Nursing Process/Analysis ° ° Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible points.
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