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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
To calculate the amount of heparin to administer, use the formula:
mL of heparin=units available units ordered×1mL available
Substituting the values given in the question, we get:
mL of heparin=100004000×11=0.4
Therefore, the nurse should administer 0.4 mL of heparin.
Normal ranges for heparin therapy vary depending on the condition being treated and the laboratory method used to measure APTT.
A general range is 60 to 80 seconds or 1.5 to 2.5 times the control value.
Correct Answer is D
Explanation
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
The provider should be informed of this change as soon as possible to prevent further complications.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.
While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.
While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.
While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
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