A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Increased pulse rate

Decreased blood pressure

Skeletal muscle weakness

Warm and pink skin

Distended neck veins

Answer and Explanation

Correct Answer : E

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

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Correct Answer is C

Explanation

A. Arrange for the patient to receive gamma globulin.

Gamma globulin is a blood product that contains antibodies and is sometimes used for post-exposure prophylaxis in certain situations, such as for individuals who are immunocompromised or pregnant and have been exposed to varicella (chickenpox) or measles. However, for a frail, older adult who had chickenpox as a child and has been exposed to varicella again, arranging for gamma globulin may not be necessary if the patient is already immune to chickenpox.

B. Assess frequently for herpes zoster.

Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. While exposure to varicella can increase the risk of developing shingles in individuals who are susceptible, frequent assessment for herpes zoster is not necessary in this case if the patient is known to have had chickenpox in the past.

C. Be aware of the patient's immunity to chickenpox.

This option is the correct choice. Since the patient had chickenpox as a child, they likely have immunity to chickenpox. Being aware of this immunity helps the nurse understand that the patient may not develop chickenpox again even after exposure to varicella.

D. Encourage the patient to have a pneumonia vaccine.

Encouraging the patient to have a pneumonia vaccine is unrelated to the immediate concern of exposure to varicella. While pneumonia vaccines are important for older adults, especially those who are frail, the priority in this scenario is to determine the patient's immunity to chickenpox due to prior infection.

A. Stop the infusion of IV fluids B. Apply cold compresses to the IV site C. Elevate the extremity on a pillow D. Flush the catheter with normal saline

Correct Answer is A

Explanation

A. Stop the infusion of IV fluids:

This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.

B. Apply cold compresses to the IV site:

Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.

C. Elevate the extremity on a pillow:

Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.

D. Flush the catheter with normal saline:

Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.

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A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

Correct Answer is C

Explanation

A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

Correct Answer is A

Explanation

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