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

Pruritus is a common adverse effect of morphine administered via continuous epidural infusion. It is caused by the release of histamine from mast cells in the skin. Pruritus can be treated with antihistamines or opioid antagonists. Choice A is wrong because gastric bleeding is not a common adverse effect of morphine administered via continuous epidural infusion.

Gastric bleeding can occur due to peptic ulcer disease, nonsteroidal anti inflammatory drugs (NSAIDs), or anticoagulants.

Choice C is wrong because cough is not a common adverse effect of morphine administered via continuous epidural infusion.

Cough can be caused by respiratory infections, asthma, or chronic obstructive pulmonary disease (COPD).

Choice D is wrong because tachypnea is not a common adverse effect of morphine administered via continuous epidural infusion.

Tachypnea can be caused by hypoxia, anxiety, pain, or fever. Morphine can cause respiratory depression, which is characterized by bradypnea, not tachypnea.

A. Plan to self-administer this medication for the next 6 months. B. Administer the medication into one nostril once per week. C. Lie down for 1 hour after administering the medication. D. Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose.

Correct Answer is B

Explanation

This is the recommended dosage for cyanocobalamin nasal spray for pernicious anaemia and vitamin B12 deficiency. Cyanocobalamin nasal gel is used to prevent a lack of vitamin B12 that may be caused by various factors.

Choice A is wrong because the duration of treatment depends on the individual’s response and blood levels of vitaminB. Some people may need to use this medication for longer than 6 months.

Choice C is wrong because there is no need to lie down for 1 hour after administering the medication.

This may cause nasal irritation or drainage.

Choice D is wrong because using a nasal decongestant 15 minutes before the medication may interfere with the absorption of cyanocobalamin. If you have a stuffy nose, you should talk to your doctor about alternative ways to take vitaminB.

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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

A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is teaching a client who has pernicious anemia to self-administer nasal cyanocobalamin. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to initiate IV therapy for a client. Which of the following sites should the nurse use to place the peripheral IV catheter?

A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?

A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?

A nurse is providing teaching to a client who has a new prescription for paroxetine. The nurse should instruct the client to monitor for which of the following adverse effects?

A nurse is receiving a medication prescription by telephone from a provider. The provider states, “Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain.” How should the nurse transcribe the prescription in the client’s medical record?

A nurse is caring for a client who has major depression and a new prescription for citalopram. Which of the following adverse effects is the priority for the nurse to report to the provider?

A nurse is administering 4 mg of hydromorphone to a client by mouth every 4 hr. The medication is provided as hydromorphone 8 mg per tablet. Which of the following actions is appropriate for the nurse to take?