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

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) PTT (Partial Thromboplastin Time): While the PTT is a laboratory test used to assess the intrinsic pathway of the coagulation cascade and monitor the effectiveness of heparin therapy, it is not routinely used to monitor warfarin therapy. Therefore, reviewing the PTT prior to administering warfarin is not necessary.

B) PT (Prothrombin Time): Prothrombin time measures the extrinsic pathway of the coagulation cascade and is commonly used to monitor warfarin therapy. Since warfarin works by inhibiting vitamin K-dependent clotting factors, such as factors II, VII, IX, and X, monitoring the PT allows for the assessment of the anticoagulant effect of warfarin and helps guide dosing adjustments. Therefore, reviewing the PT prior to administering warfarin is essential to ensure appropriate anticoagulation therapy.

C) WBC (White Blood Cell Count): The white blood cell count is not directly related to warfarin therapy monitoring. While an elevated white blood cell count may indicate infection, it is not specific to warfarin therapy and does not influence the administration of the medication.

D) Total iron-binding capacity: Total iron-binding capacity is a laboratory test used to assess iron status and is not relevant to monitoring warfarin therapy. It measures the body's ability to bind and transport iron in the blood, and its results are not indicative of warfarin's anticoagulant effect or dosage adjustments.

A. The client will wear his reading glasses when drawing up a dose of insulin glargine. B. The client will administer insulin glargine before each meal. C. The client will use the deltoid muscle as an injection site. D. The client will take an additional dose of insulin glargine prior to exercise.

Correct Answer is A

Explanation

A) The client will wear his reading glasses when drawing up a dose of insulin glargine: This is the correct expected outcome. Older adults may experience visual changes that affect their ability to see clearly. Wearing reading glasses or using other visual aids can help ensure accurate measurement and administration of insulin glargine, reducing the risk of dosing errors.

B) The client will administer insulin glargine before each meal: This statement is incorrect. Insulin glargine is a long-acting insulin analog that is typically administered once daily at the same time each day, rather than before each meal. It provides a steady level of insulin over a 24-hour period and is not directly related to meal timing.

C) The client will use the deltoid muscle as an injection site: Using the deltoid muscle as an injection site for insulin glargine is not recommended. Insulin glargine is usually injected suIcutaneously into the abdomen, thigh, or upper arm. The deltoid muscle may not provide consistent absorption of insulin and is not commonly used for insulin injections.

D) The client will take an additional dose of insulin glargine prior to exercise: Taking an additional dose of insulin glargine prior to exercise is not a typical part of insulin glargine therapy. Adjustments to insulin doses for exercise should be made under the guidance of a healthcare provider, and additional doses of insulin glargine are not usually recommended for this purpose.

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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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