A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?
Decreased bowel sounds.
Bilateral muscle weakness.
Thready pulse.
Distended neck veins
The Correct Answer is D
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
According to the CDC, people with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine. However, people with egg allergy can get a flu vaccine. The CDC also states that people who have had a severe allergic reaction to a dose of influenza vaccine should not get that flu vaccine again and might not be able to receive other influenza vaccines. Therefore, a nurse should report an egg allergy to the provider as a possible contraindication to receiving the vaccine.
Choice A is wrong because shellfish is not an ingredient in a flu vaccine and is not a contraindication to receiving the vaccine.
Choice C is wrong because milk is not an ingredient in a flu vaccine and is not a contraindication to receiving the vaccine.
Choice D is wrong because peanuts are not an ingredient in a flu vaccine and are not a contraindication to receiving the vaccine.
Correct Answer is D
Explanation
A WBC count of 5,000/mm3 is low and could indicate leukopenia, a possible side effect of amitriptyline. Leukopenia increases the risk of infection and should be reported to the provider.
Choice B is wrong because a total bilirubin of 1.5 mg/dL is within the normal range of 0.3 to 1.9 mg/dL.
Choice C is wrong because a Hct of 44% is within the normal range of 37% to 48% for women and 45% to 52% for men.
Choice D is wrong because a potassium level of 4.2 mEq/L is within the normal range of 3.5 to 5.0 mEq/L.
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