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 C
Explanation
Choice A Reason:
Meloxicam is incorrect. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used primarily for managing mild to moderate pain and inflammation. While it can provide relief for mild pain, it may not be potent enough to effectively manage severe pain, especially in cases of advanced cancer-related pain, where stronger analgesics are often necessary.
Choice B Reason:
Aspirin is incorrect. Aspirin, like meloxicam, is an NSAID used for mild to moderate pain relief and has anti-inflammatory properties. While it can be effective for certain types of pain, it's generally not the first choice for severe pain management, particularly in cases of advanced cancer-related pain where stronger opioids are typically required for adequate relief.
Choice C Reason:
Hydromorphone is correct. Hydromorphone is a potent opioid analgesic used to manage severe pain, especially in cancer-related pain or post-operative settings. In cases of severe pain, opioids like hydromorphone are commonly utilized due to their effectiveness in providing relief.
Choice D Reason:
Caldofor is incorrect. The term "Caldofor" does not appear to correspond to any recognized medication commonly used for pain relief. It's possible that this might be a misspelling or an unfamiliar or less common drug name. Without a specific drug identification, it's challenging to assess its suitability or effectiveness for managing severe pain associated with pancreatic cancer.
Correct Answer is ["60"]
Explanation
Step 1: Determine the Lidocaine Concentration
- The solution contains 2 grams (2000 mg) of lidocaine in 500 mL.
- To find the amount of lidocaine per mL:
2000 mg ÷ 500 mL = 4 mg/mL
Step 2: Calculate the Total Dose per Hour
- The prescribed infusion rate is 4 mg per minute.
- In 1 hour (60 minutes), the total dose is:
4 mg/min × 60 min = 240 mg/hr
Step 3: Determine the Infusion Rate in mL/hr
- Since each mL contains 4 mg of lidocaine:
240 mg ÷ 4 mg/mL = 60 mL/hr
The nurse should set the IV pump to 60 mL/hr for the continuous IV infusion of lidocaine at a rate of 4 mg/min.
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