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 C

Explanation

Urticaria, also known as hives, is a common sign of an allergic reaction to penicillin. An allergic reaction is an abnormal response of the immune system to the drug. Other signs and symptoms of penicillin allergy may include skin rash, itching, fever, swelling, shortness of breath, wheezing, runny nose, itchy eyes, and anaphylaxis. Anaphylaxis is a rare but life-threatening condition that affects multiple body systems and requires immediate emergency treatment.

Choice A is wrong because pallor is not a typical sign of an allergic reaction to penicillin.

Pallor means pale skin and may be caused by other conditions such as anemia or shock.

Choice B is wrong because bradycardia is not a typical sign of an allergic reaction to penicillin.

Bradycardia means slow heart rate and may be caused by other conditions such as heart block or medication side effects.

Choice D is wrong because dyspepsia is not a typical sign of an allergic reaction to penicillin.

Dyspepsia means indigestion and may be caused by other conditions such as gastritis or peptic ulcer.

A. Morphine 6 mg IV push every 3 hr PRN acute pain. B. MS6 mg IV push every 3 hr PRN acute pain. C. MSO4 6 mg IV push every 3 hr PRN acute pain. D. Morphine 6.0 mg IV push every 3 hr PRN acute pain.

Correct Answer is A

Explanation

This is because it uses the full name of the drug, the exact dose, the route of administration, the frequency, and the indication for use. It also avoids any abbreviations that could be confused with other drugs or measurements.

Choice B is wrong because MS is an abbreviation for morphine sulfate which could be mistaken for magnesium sulfate.

Choice C is wrong because MSO4 is an abbreviation for morphine sulfate that could be mistaken for magnesium sulfate.

Choice D is wrong because 6.0 mg could be misread as 60 mg and lead to a tenfold overdose.

Normal ranges for morphine dosage depend on the route of administration, the indication, and the patient’s tolerance and response.

For acute pain, the usual oral dose is 10 to 30 mg every 4 hours as needed. For chronic pain, the usual oral dose is 15 to 30 mg every 8 to 12 hours as needed.

For intravenous (IV) administration, the usual dose is 2.5 to 15 mg every 4 hours as needed.

The morphine equivalent daily dose (MEDD) is a concept that attempts to establish an equivalency in terms of dose when comparing any opioid to morphine.

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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 preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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