A nurse is assessing a client who is experiencing fluid volume excess. Which of the following findings should the nurse expect?
Poor skin turgor
Thready pulse
Crackles in lung bases
Flat neck veins
The Correct Answer is C
Rationale
A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.
B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.
C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.
D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,E,D,C
Explanation
Correct Answer is A
Explanation
Rationale
A. Insulin Glargine 20 units SUBQ qd: The abbreviation "qd" can be misinterpreted and is considered unsafe in medication orders. Insulin requires precise dosing and timing to prevent hypo- or hyperglycemia. The nurse should clarify the prescription with the provider and document "once daily" to ensure safe administration.
B. Ceftriaxone 250 mg IM stat: This prescription is clear regarding the medication, dose, route, and timing. "Stat" indicates immediate administration, which is understandable and requires no clarification.
C. Diazepam 5 mg PO Q8h PRN muscle spasms: The prescription clearly specifies the dose, route, frequency, and indication. The nurse can safely administer as needed without needing clarification.
D. Digoxin 0.5 mg IV once: The prescription provides complete information about the medication, dose, route, and single administration. No ambiguous abbreviations are present, so clarification is unnecessary.
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