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 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.

A. Grasp skin between thumb and forefinger throughout the injection. B. Aspirate the syringe prior to injecting the heparin. C. Use the Z-track method to administer the medication. D. Gently massage the site following the injection.

Correct Answer is A

Explanation

A) Grasp skin between thumb and forefinger throughout the injection: This is the correct answer. Grasping the skin between the thumb and forefinger creates tension, which helps to stabilize the tissue during the injection. This technique reduces the risk of tissue damage and minimizes bleeding following the injection of heparin subcutaneously.

B) Aspirate the syringe prior to injecting the heparin: Aspiration is not necessary for subcutaneous injections, as the risk of intravascular injection is minimal. Aspirating the syringe can increase discomfort for the client and is not recommended for subcutaneous injections.

C) Use the Z-track method to administer the medication: The Z-track method is used for intramuscular injections to minimize medication leakage into the subcutaneous tissue. However, heparin is typically administered subcutaneously, and the Z-track method is not appropriate for this route of administration.

D) Gently massage the site following the injection: Massaging the site following a subcutaneous injection of heparin can increase the risk of bleeding and hematoma formation. Therefore, this action should be avoided to minimize bleeding at the injection site.

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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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