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?
Bilateral muscle weakness
Thready pulse
Decreased bowel sounds
Distended neck veins
The Correct Answer is D
Choice A Reason:
Bilateral muscle weakness is not typically associated specifically with fluid volume excess. Muscle weakness can result from various causes, such as electrolyte imbalances or certain medical conditions, but it's not a primary manifestation of fluid volume excess.
Choice B Reason:
Thready pulse is not correct. A thready pulse refers to a weak and barely palpable pulse. This is more commonly associated with conditions like shock or reduced cardiac output rather than fluid volume excess.
Choice C Reason:
Decreased bowel sounds is not correct. Reduced or absent bowel sounds may indicate gastrointestinal issues, but they are not a direct manifestation of fluid volume excess. Increased bowel sounds might be more associated with certain types of gastrointestinal disturbances or fluid imbalances, but decreased sounds are not a typical sign of fluid volume excess.
Choice D Reason:
Distended neck veins is correct. In a client experiencing fluid volume excess, distended neck veins can often be observed due to increased venous pressure. This occurs as a result of the body retaining more fluid than it can handle, leading to an increase in blood volume and pressure within the vascular system. This can cause the jugular veins in the neck to appear distended or prominent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Discard the medication if it is yellow is incorrect. While amphotericin B lipid complex can have a yellowish color, it's important to follow specific guidelines provided by the manufacturer or pharmacy regarding any discoloration or changes in the medication's appearance. Discoloration could indicate degradation or contamination, and it's crucial to adhere to specific institutional policies in such cases.
Choice B Reason:
Administer the medication over 2 hr is incorrect. Amphotericin B lipid complex is usually given over a longer duration (e.g., several hours) due to the potential for infusion-related reactions. Intermittent IV bolus administration over 2 hours might not be appropriate and can increase the risk of adverse reactions.
Choice C Reason:
Use a gravity flow set is incorrect. For medications like amphotericin B lipid complex, which often require precise infusion rates and careful monitoring, using an IV infusion pump is usually recommended instead of a gravity flow set. An infusion pump allows for more accurate control of the infusion rate and reduces the risk of errors.
Choice D Reason:
Prime the tubing with 0.9% sodium chloride is correct. Amphotericin B lipid complex should be administered according to specific instructions and precautions. Priming the IV tubing with 0.9% sodium chloride helps ensure that the medication is effectively delivered to the patient and that the medication is not affected by remnants of previous IV solutions in the tubing.
Correct Answer is B
Explanation
Choice A Reason:
Contact the provider to clarify the prescription is not appropriate. Contacting the provider might not be necessary in this case. The prescription specifies "NOW," indicating an urgent administration, which is a clear directive to administer the medication promptly without further clarification.
Choice B Reason:
Administer the medication within 90 minutes is appropriate. "NOW" typically implies an urgent need for administration, and within a hospital setting, "NOW" often indicates a timeframe of around 90 minutes for prompt administration of the medication.
Choice C Reason:
Notify the pharmacy to send the medication immediately is inappropriate. With the prescription stating "NOW," the need for immediate administration usually requires using the hospital's available stock of the medication rather than waiting for delivery from the pharmacy. This action might cause a delay in administration.
Choice D Reason:
Inform the client there is a prescription available if needed is inappropriate. This option is not suitable in this scenario. "NOW" in the prescription implies the immediate need for administration, so informing the client about the availability of the prescription doesn't align with the urgency implied by the directive "NOW."
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