Practice Question
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)
Answer Choices:
Correct Answer:
Palpate the rate and volume of the pulse.
Rationale:
💓 A. Palpate the rate and volume of the pulse
💓 In fluid volume excess, the heart works harder to circulate the extra volume, leading to a bounding or increased-volume pulse.
💓 The PN should palpate pulses to assess for fullness, rate, and rhythm, which may reveal signs of cardiovascular strain or overload.
💓 A fast, bounding pulse may indicate the heart is compensating for circulatory congestion, often seen in fluid overload states like heart failure or renal dysfunction.
⚖️ C. Measure body weight at the same time daily
⚖️ Daily weights are one of the most sensitive indicators of fluid volume status.
⚖️ A sudden weight gain (e.g., 2–3 pounds in 24 hours) often reflects fluid retention, not fat accumulation.
⚖️ It is essential to measure weight at the same time, on the same scale, and in similar clothing for consistency.
⚖️ This helps detect early signs of fluid overload before symptoms worsen.
💧 D. Observe the color and amount of urine
💧 In fluid overload, the kidneys may produce either increased dilute urine (if functioning properly) or decreased urine (in cases of renal compromise).
💧 Urine that is pale and copious may reflect the body’s effort to excrete excess fluid, whereas dark or scant urine may suggest renal involvement or retention.
💧 Monitoring urine helps evaluate fluid balance, renal perfusion, and ongoing fluid management.
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This question is from PN Hesi Exit-2025 Exam 1 which contains 72 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN HESI Exit Exam(s)
- Domain: LPN HESI Exit-2025
- Answer Choices: 5