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?

Thready pulse

Decreased bowel sounds

Bilateral muscle weakness

Distended neck veins

Answer and Explanation

The Correct Answer is D

A. Thready pulse:
A thready pulse is more indicative of fluid volume deficit or inadequate cardiac output, not fluid volume excess.
B. Decreased bowel sounds:
Decreased bowel sounds are not a specific sign of fluid volume excess. They may be associated with various gastrointestinal issues but are not directly related to fluid volume status.
C. Bilateral muscle weakness:
Bilateral muscle weakness is not a specific manifestation of fluid volume excess. It may be associated with electrolyte imbalances or other neuromuscular issues.
D. Distended neck veins:
This is the correct answer. Distended neck veins are a classic sign of fluid volume excess or overload. Increased venous pressure from excess fluid can lead to distension of the jugular veins in the neck. This finding is often seen in conditions such as heart failure or renal failure where there is an inability to adequately excrete or distribute fluids.

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Correct Answer is C

Explanation

A. A vein that feels hard to the touch:
A vein that feels hard to the touch may indicate thrombosis or inflammation and is not a suitable site for catheter insertion.
B. A vein in the client's dominant arm:
The choice of arm may depend on the client's preference, but it is not a strict rule. The nurse can choose a suitable vein in either arm based on factors such as accessibility and vein condition.
C. A vein proximal to the previous site:
This is the correct answer. Placing the catheter proximal (above or upstream) to the previous site helps minimize the risk of complications such as infiltration and thrombophlebitis at the new site. It allows for optimal vein health and reduces the likelihood of complications associated with repeated punctures in the same area.
D. A vein on the client's wrist:
Veins on the wrist may be smaller and more prone to complications. It is generally recommended to choose larger, more accessible veins for catheter insertion.

A. "You will need to undergo tuberculin skin tests every 6 months while taking medication for your disease" B. "You will need to take two or more medications to treat your disease C. You should anticipate taking medication to treat your disease for at least the next 3 years D. You should report monthly to have your blood drawn to monitor kidney function while taking medication

Correct Answer is B

Explanation

A. "You will need to undergo tuberculin skin tests every 6 months while taking medication for your disease."
Tuberculin skin tests are typically used for screening and diagnosis, not for monitoring the effectiveness of tuberculosis treatment. Monitoring for treatment effectiveness involves assessing symptoms, sputum cultures, and other diagnostic tests.
B. "You will need to take two or more medications to treat your disease."
This is the correct answer. Tuberculosis is usually treated with a combination of antibiotics to prevent the development of drug resistance. Multidrug therapy is a standard approach to tuberculosis treatment.
C. "You should anticipate taking medication to treat your disease for at least the next 3 years."
The duration of tuberculosis treatment is generally shorter than 3 years. The standard treatment duration is typically 6 to 9 months, depending on the specific regimen used.
D. "You should report monthly to have your blood drawn to monitor kidney function while taking medication."
Monitoring kidney function is important for some medications, but it is not a standard monthly requirement for tuberculosis treatment. Monitoring typically involves assessing liver function, as certain tuberculosis medications can affect the liver.

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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?

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