A nurse is assessing a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Distended neck veins

Elevated hematocrit level

Shortness of breath

Weight gain

Answer and Explanation

The Correct Answer is B

A) Distended neck veins: Distended neck veins are typically associated with fluid volume excess rather than deficit. In heart failure, venous congestion can cause jugular venous distention, indicating fluid volume overload rather than deficit. Therefore, this finding would not suggest fluid volume deficit in a client with heart failure receiving furosemide.
B) Elevated hematocrit level: Fluid volume deficit, also known as dehydration or hypovolemia, is characterized by a loss of both water and electrolytes from the body, leading to a relative increase in the concentration of red blood cells and other blood components. This increase in concentration results in an elevated hematocrit level, which is a common laboratory finding in clients with fluid volume deficit. Furosemide, a loop diuretic, is commonly used to manage fluid overload in clients with heart failure by promoting diuresis and reducing excess fluid retention. However, excessive diuresis with furosemide can lead to fluid volume deficit if not adequately monitored and managed.

C) Shortness of breath: Shortness of breath is a common symptom of heart failure, particularly when fluid accumulates in the lungs (pulmonary edema) due to fluid volume overload. While shortness of breath may be present in both fluid volume deficit and excess, it is more commonly associated with fluid volume overload in clients with heart failure.

D) Weight gain: Weight gain is indicative of fluid volume excess rather than deficit. In heart failure, weight gain often occurs due to fluid retention, reflecting an increase in total body water and extracellular fluid volume. Monitoring weight is essential in managing heart failure and assessing fluid status, but weight gain would not suggest fluid volume deficit in a client receiving furosemide for heart failure management.

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Correct Answer is B

Explanation

A) Document the administration of the medication: Documentation of medication administration is an essential step in the medication administration process, ensuring accurate recording of the time, dose, route, and client's response to the medication. However, before administering a controlled substance, the nurse should first identify the client using two identifiers to prevent medication errors.

B) Identify the client using two identifiers: This is the correct initial action. Verifying the client's identity using two identifiers, such as name and date of birth, is a crucial safety measure to ensure that the medication is administered to the correct individual. By confirming the client's identity, the nurse helps prevent medication errors and promotes patient safety.

C) Remove the medication from the medication dispensing cabinet: While obtaining the medication from the medication dispensing cabinet is necessary for administration, it should occur after confirming the client's identity. Identifying the client using two identifiers is the priority to ensure accurate medication administration.

D) Compare the amount of medication available to the inventory record: Verifying the amount of medication available against the inventory record is an important step in medication management to maintain adequate stock levels and prevent medication shortages. However, it is not the first action the nurse should take before administering a controlled substance. Confirming the client's identity is the priority to ensure safe medication administration.

A. Ginkgo biloba B. Valerian C. Coenzyme Q10 D. Probiotics

Correct Answer is A

Explanation

A) Ginkgo biloba: This is the correct answer. Ginkgo biloba is contraindicated for concurrent use with warfarin because it can increase the risk of bleeding due to its anticoagulant properties. It can potentiate the effects of warfarin, leading to an increased risk of bruising and bleeding complications.

B) Valerian: While valerian is an herbal supplement used for its sedative effects, it does not typically interact significantly with warfarin. However, caution should still be exercised when combining valerian with any medication due to its potential to cause drowsiness and enhance the effects of other central nervous system depressants.

C) Coenzyme Q10: Coenzyme Q10 is a dietary supplement that is generally well-tolerated and does not have significant interactions with warfarin. It is often used as an antioxidant and for various cardiovascular conditions.

D) Probiotics: Probiotics are beneficial bacteria that can aid in gut health but are unlikely to interact significantly with warfarin. However, it is essential to monitor for any potential changes in gastrointestinal function when starting probiotics concurrently with warfarin.

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A nurse is assessing a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

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