Author Question: For a client with a nursing diagnosis of Fluid volume excess, the nurse is alert to which one of the ... (Read 56 times)

kaid0807 · **on:** Jul 22, 2018

For a client with a nursing diagnosis of Fluid volume excess, the nurse is alert to which one of the following signs and symptoms?

a. Tachycardia
b. Hypertension
c. Dry mucous membranes
d. Fever

Question 2

The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the following actions would be most important to include in this patient's preparation?

a. Ascertain that the surgical site has been correctly marked.
b. Ascertain where the family will be located during the procedure.
c. Place the patient in a clean surgical gown.
d. Ask the patient to remove all hairpins and cosmetics.

carolinefletcherr · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Hypertension is a symptom of fluid volume excess.
Tachycardia is associated with fluid volume deficit.
Dry mucous membranes are symptomatic of fluid volume deficit/dehydration, not excess fluid.
Fever is a symptom of fluid volume deficit.

Answer to Question 2

A
Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol has been implemented and is used with all invasive procedures. Part of this protocol includes marking the operative site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient to remove all hairpins and cosmetics are important but are not most important in this list of items.