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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Notify the nurse manager about the incident: While it's important to report medication errors,’the immediate concern should be the client's well-being. Notifying the nurse manage’ can be done after addressing the client's condition.
B) Prepare and file an inc’dent report: Filing an incident report is necessary to document the error, but it should not be the first action taken. Ensuring the client's safety and well-being is the priority.’
C) Notify the provider of the medication administration: While it's important for the provider to be infor’ed of medication errors, the immediate concern should be assessing the client's response to the medication.
D) Examin’ the client's vital signs and condition: This is the’correct answer. The nurse's first action should be to assess the client's vital signs and condition to determine’any adverse effects of the medication. Digoxin is a medication used to treat heart conditions, but it can cause harm if administered when the heart rate is already low. Monitoring the client closely for signs of bradycardia or other adverse effects is essential.
Correct Answer is B
Explanation
A) "Inject the medication into the lateral thigh": While the lateral thigh is a common site for subcutaneous injections, enoxaparin is typically administered in the abdomen. Instructing the client to inject into the lateral thigh may lead to incorrect administration. Therefore, this instruction is not appropriate for enoxaparin administration.
B) "Ensure that the air bubble remains in the syringe": This instruction is correct. Enoxaparin prefilled syringes usually come with an air bubble to help ensure the full dose is delivered. Instructing the client to keep the air bubble in the syringe helps prevent the loss of medication during administration, ensuring that the full dose is delivered subcutaneously.
C) "Release the skin fold before injecting the medication": Releasing the skin fold before injecting the medication helps ensure proper needle insertion into the subcutaneous tissue and facilitates medication absorption. This instruction is generally appropriate for subcutaneous injections but is not specific to enoxaparin administration.
D) "Rub the site after injecting the medication": Rubbing the injection site after administration is not recommended, as it can cause irritation and discomfort. Instead, instruct the client to gently press on the injection site without rubbing to help disperse the medication and minimize bruising or discomfort. Therefore, this instruction is not appropriate for enoxaparin administration.
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