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 B
Explanation
a.While weight changes can be concerning, they are not typically life-threatening and can occur as a common side effect of antidepressants, including citalopram. Monitoring is important, but it does not require immediate reporting.
b.This is the priority to report because confusion can indicate a serious reaction to the medication, such as serotonin syndrome, especially if it occurs in conjunction with other symptoms like agitation, hallucinations, or rapid heart rate. Confusion can also signal worsening mental status, which is critical for someone with major depression.
c.This refers to teeth grinding, which can occur with certain antidepressants. While it should be monitored and possibly addressed with interventions, it is generally not an immediate concern compared to confusion.
d.Sleep disturbances can be a side effect of citalopram and may need adjustment of treatment or recommendations for sleep hygiene, but they are not as urgent as confusion.
Correct Answer is C
Explanation
Atorvastatin is a medication that belongs to a group of drugs called statins. It is used to lower blood levels of “bad” cholesterol (low-density lipoprotein, or LDL), to increase levels of “good” cholesterol (high-density lipoprotein, or HDL), and to lower triglycerides (a type of fat in the blood). The treatment has been effective if the LDL level is reduced, as high LDL levels can increase the risk of heart disease and stroke. A normal range for LDL is less than 100 mg/dL.
Choice A is wrong because urine specific gravity is a measure of how concentrated the urine is, not how much cholesterol is in the blood. A normal range for urine specific gravity is 1.005 to 1.0304.
Choice B is wrong because BUN (blood urea nitrogen) is a measure of how well the kidneys are working, not how much cholesterol is in the blood. A normal range for BUN is 7 to 20 mg/dL.
Choice D is wrong because blood glucose is a measure of how much sugar is in the blood, not how much cholesterol is in the blood.
A normal range for blood glucose is 70 to 100 mg/dL.
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