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 A

Explanation

An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.

Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.

Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.

Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.

A. Beclomethasone. B. Estrogen-progestin combination. C. Diphenhydramine. D. Nicotine transdermal system.

Correct Answer is B

Explanation

Carbamazepine is an anticonvulsant medication that is used to treat seizures and nerve pain. It works by reducing the activity of certain nerve cells in the brain.

Choice A is wrong because beclomethasone is a corticosteroid that is used to treat asthma and allergic rhinitis. It does not interact with carbamazepine.

Choice B is correct because the estrogen-progestin combination is a hormonal contraceptive that is used to prevent pregnancy and regulate menstrual cycles. It interacts with carbamazepine because carbamazepine can increase the breakdown of estrogen and progestin in the body, making them less effective. The nurse should instruct the client to use an alternative or additional method of birth control while taking carbamazepine.

Choice C is wrong because diphenhydramine is an antihistamine that is used to treat allergies, motion sickness, and insomnia. It does not interact with carbamazepine.

Choice D is wrong because the nicotine transdermal system is a nicotine replacement therapy that is used to help people quit smoking. It does not interact with carbamazepine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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