A client is admitted to the medical unit with fluid volume overload due to heart failure. Clinical manifestations of this problem are [Select all that apply]:
Distended neck veins
Hypotension
Increased serum osmolality
Dry oral mucosa
Decreased urine specific gravity
Weight gain
Sunken anterior fontanelle
Correct Answer : A,E,F
Choice A reason: This statement is true. Distended neck veins are a sign of fluid volume overload, as they indicate increased central venous pressure and right-sided heart failure.
Choice B reason: This statement is false. Hypotension is a sign of fluid volume deficit, not fluid volume overload. Hypotension occurs when the blood pressure is too low to perfuse the vital organs.
Choice C reason: This statement is false. Increased serum osmolality is a sign of fluid volume deficit, not fluid volume overload. Increased serum osmolality occurs when the blood concentration of solutes, such as sodium and glucose, is too high due to fluid loss.
Choice D reason: This statement is false. Dry oral mucosa is a sign of fluid volume deficit, not fluid volume overload. Dry oral mucosa occurs when the oral cavity is dehydrated due to fluid loss.
Choice E reason: This statement is true. Decreased urine specific gravity is a sign of fluid volume overload, as it indicates diluted urine and impaired kidney function.
Choice F reason: This statement is true. Weight gain is a sign of fluid volume overload, as it indicates fluid retention and edema.
Choice G reason: This statement is false. Sunken anterior fontanelle is a sign of fluid volume deficit, not fluid volume overload. Sunken anterior fontanelle occurs when the soft spot on the baby's head is depressed due to fluid loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false. IV morphine sulfate is a pain medication that can be given as needed to the postoperative patient. It does not affect the serum sodium level.
Choice B reason: This statement is false. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can be used to treat hyponatremia, or low serum sodium level. It provides both glucose and sodium to the patient.
Choice C reason: This statement is true. 5% dextrose in water is a hypotonic solution that can cause further dilution of the serum sodium level. It can worsen the hyponatremia and increase the risk of cerebral edema and seizures.
Choice D reason: This statement is false. Neurologic assessment Q2 hours is a necessary intervention for a patient with hyponatremia, as it can monitor for signs of neurologic deterioration such as confusion, lethargy, or coma.
Correct Answer is A
Explanation
Choice A reason: Lispro (Humalog) is a type of insulin that is used for mealtime coverage. It is a rapid-acting insulin that starts to work within 15 minutes, peaks in about an hour, and lasts for 2 to 4 hours. It mimics the natural insulin response to food intake, and helps to lower the blood glucose level after meals. The nurse will discuss using lispro for mealtime coverage, and instruct the patient to inject it within 15 minutes before or after eating.
Choice B reason: NPH (Humulin N) is a type of insulin that is not used for mealtime coverage. It is an intermediate-acting insulin that starts to work within 2 to 4 hours, peaks in 4 to 12 hours, and lasts for 12 to 18 hours. It provides a steady background of insulin throughout the day, and helps to control the blood glucose level between meals and overnight. The nurse will discuss using NPH for basal coverage, and instruct the patient to inject it once or twice a day, usually in the morning and/or evening.
Choice C reason: Detemir (Levemir) is a type of insulin that is not used for mealtime coverage. It is a long-acting insulin that starts to work within 1 to 2 hours, has no peak, and lasts for up to 24 hours. It provides a constant level of insulin throughout the day, and helps to maintain the blood glucose level at a stable range. The nurse will discuss using detemir for basal coverage, and instruct the patient to inject it once or twice a day, depending on the individual needs.
Choice D reason: Glargine (Lantus) is a type of insulin that is not used for mealtime coverage. It is a long-acting insulin that starts to work within 1 to 2 hours, has no peak, and lasts for up to 24 hours. It provides a constant level of insulin throughout the day, and helps to maintain the blood glucose level at a stable range. The nurse will discuss using glargine for basal coverage, and instruct the patient to inject it once a day, usually at the same time every day.
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