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 A
Explanation
Choice A Reason:
The medication vial sat at room temperature for 2 hr before it was administered is correct. Medications like filgrastim typically have specific storage requirements, including temperature control. Allowing the medication vial to sit at room temperature for an extended period may compromise its stability or effectiveness, leading to potential concerns regarding medication safety. Reporting incidents related to improper medication storage is essential to ensure patient safety and prevent similar occurrences in the future.
Choice B Reason:
The client's absolute neutrophil count was 2,500/mm3 before the medication was administered. Is incorrect. A normal or adequate absolute neutrophil count (ANC) of 2,500/mm3 before administering filgrastim is not an adverse event that requires an incident report.
Choice C Reason:
The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered. Is incorrect. Flushing the IV line with dextrose 5% in water is a standard practice and not considered an adverse event or reason for filing an incident report.
Choice D Reason:
The client had chemotherapy 12 hr before the medication was administered. Is incorrect. The timing of previous chemotherapy administration, in this case, doesn't inherently suggest an adverse event requiring an incident report.
Correct Answer is D
Explanation
Choice A Reason:
Decrease the dose of the medication is incorrect. Lowering the dose could potentially drop the INR below the therapeutic range, increasing the risk of clot formation.
Choice B Reason:
Increase the dose of the medication is incorrect. Raising the dose might push the INR above the therapeutic range, increasing the risk of bleeding.
Choice C Reason:
Withhold the medication is incorrect. Withholding the medication might lead to inadequate anticoagulation and an increased risk of clot formation.
Choice D Reason:
Administer the current dose of the medication. An INR of 2.5 is within the therapeutic range for many indications, including atrial fibrillation. This means the blood is appropriately anticoagulated to prevent clot formation without an excessive risk of bleeding. In this scenario, maintaining the current dose of warfarin is often appropriate to sustain the desired therapeutic effect.
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