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

Answer and Explanation

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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Correct Answer is B

Explanation

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

A. Expel the air bubble from the syringe prior to injection. B. Apply firm pressure to the injection site following administration. C. Insert the syringe needle halfway into the client’s skin. D. Administer the medication into the client’s muscles.

Correct Answer is B

Explanation

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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