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?
Weight gain
Distended neck veins
Shortness of breath
Elevated hematocrit level
The Correct Answer is D
Choice A Reason:
Weight gain is incorrect. Weight gain is typically associated with fluid volume excess rather than deficit. In heart failure, fluid retention can lead to weight gain due to excess fluid accumulation in the body.
Choice B Reason:
Distended neck veins is incorrect. Distended neck veins are a sign of fluid volume excess, commonly seen in heart failure due to increased venous pressure and fluid retention.
Choice C Reason:
Shortness of breath is incorrect.: Shortness of breath is often associated with fluid accumulation in the lungs, known as pulmonary edema, which is a manifestation of fluid volume excess or fluid overload in heart failure.
Choice D Reason:
Elevated hematocrit level is correct. Furosemide is a diuretic that promotes diuresis (increased urine output), leading to fluid loss. When a client experiences fluid volume deficit or dehydration due to increased diuresis, there is a concentration of red blood cells in the blood, resulting in an elevated hematocrit level. This occurs because the blood becomes more concentrated when there's less fluid volume available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"I will have my partner tilt their head back while I am instilling the drops." Is incorrect. Tilting the head back is not typically recommended for administering optic medication as it might cause the medication to flow out instead of remaining in the ear canal.
Choice B Reason:
"I will make sure the solution is cool prior to instilling the drops." Is incorrect. The temperature of the solution usually doesn't need to be adjusted before instilling optic drops unless directed otherwise by specific medication instructions or healthcare provider guidance.
Choice C Reason:
"I will pull the pinna upward and outward prior to instilling the drops." Is correct statement. Pulling the pinna (outer ear) upward and outward helps straighten the ear canal in adults, facilitating the proper administration of optic (ear) drops. This action helps ensure that the medication reaches the ear canal effectively.
Choice D Reason:
"I will have my partner lie down on their back while I am instilling the drops." Is incorrect statement.
Having the partner lie down on their back might not be necessary for administering optic medication and might not be the optimal position for effective instillation.
Correct Answer is D
Explanation
Choice A Reason:
"I will check the client's INR before administering the heparin." is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps reduce the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in minimizing bleeding at the injection site.
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