A nurse is assessing a client who has a continuous IV infusion. The nurse should identify that which of the following findings is a manifestation of fluid overload?
Elevated blood pressure
Decreased pulse rate
Decreased gastrointestinal motility
Flattened neck veins
The Correct Answer is A
A. Elevated blood pressure: Excess fluid in the vascular system increases circulating volume, which raises blood pressure. This is a common early sign of fluid overload and can lead to additional complications if not addressed promptly.
B. Decreased pulse rate: Fluid overload typically causes an increased pulse rate as the heart works harder to manage the extra volume. A decreased pulse is not a usual manifestation of fluid overload.
C. Decreased gastrointestinal motility: Fluid overload does not directly reduce gastrointestinal motility. Bowel slowing is more commonly associated with medications, immobility, or other systemic conditions rather than excess IV fluid.
D. Flattened neck veins: Fluid overload usually causes distended neck veins due to increased central venous pressure. Flattened neck veins suggest hypovolemia or low circulating blood volume rather than overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tell the client they will get used to the side effects: Minimizing or dismissing the client’s concerns about medication side effects does not respect their autonomy or provide safe guidance. It could undermine trust and does not address the risks of alternative therapies.
B. Check the client's other medications for potential interactions: Saw palmetto can interact with other medications, including anticoagulants and hormonal therapies. Reviewing the client’s current medications ensures safety and helps prevent adverse effects if they choose to use the herbal supplement.
C. Report the client's refusal to the nursing supervisor: While documentation of medication refusal is necessary, immediately reporting without addressing safety and interactions does not support client-centered care or informed decision-making.
D. Explain how harmful herbal medications can be: Not all herbal supplements are inherently harmful. Providing balanced information about potential benefits, risks, and interactions is more appropriate than blanket statements that may seem judgmental.
Correct Answer is A
Explanation
A. Dual-energy x-ray absorptiometry (Dexa scan): Dexa scans measure bone mineral density and are the standard tool for diagnosing osteoporosis and monitoring the effectiveness of treatments like alendronate. Changes in bone density over time indicate how well the medication is working.
B. Urine specific gravity: This test evaluates kidney function and hydration status but does not provide information about bone density or the effectiveness of osteoporosis therapy.
C. Lumbar puncture: A lumbar puncture assesses cerebrospinal fluid for neurological conditions. It has no role in evaluating osteoporosis treatment or bone health.
D. Hemoglobin A1C (Hb A1C): HbA1C measures average blood glucose over several months, used in diabetes management. It does not reflect changes in bone density or the impact of alendronate therapy.
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