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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:
"I will check the client's INR before administering the heparin." is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps reduce the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in minimizing bleeding at the injection site.

A. Sodium 141 mEq/L B. Potassium 2.5 mEq/L C. WBC count 8,000/mm3 D. INR 1.0

Correct Answer is B

Explanation

Choice A Reason:
Sodium 141 mEq/L is incorrect. This value is within the normal range (usually around 135-145 mEq/L).
Choice B Reason:
Potassium 2.5 mEq/ is correct. Furosemide, a loop diuretic, can lead to potassium loss through increased urine output. If a client already has a low potassium level (hypokalemia), administering furosemide can further decrease potassium levels, potentially causing or worsening hypokalemia. Hypokalemia can lead to various complications, including cardiac arrhythmias.
Choice C Reason:
WBC count 8,000/mm3 is incorrect. This value falls within the normal range for white blood cell count.
Choice D Reason:
INR 1.0: An INR of 1.0 is within the normal range for a person not on anticoagulation therapy.

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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

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Explanation

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