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 A

Explanation

A. Transparent membrane dressing:
This is the correct answer. Transparent dressings are commonly used to cover peripheral IV catheter insertion sites. They provide a clear view of the site, allow for easy monitoring, and create a barrier against contamination while maintaining a moist environment.

B. Hydrocolloid dressing:
Hydrocolloid dressings are generally used for wounds with minimal exudate. They are not typically used for securing peripheral IV catheters.

C. Sterile gauze bandage:
Sterile gauze bandages may be used for specific types of wounds but are not the preferred choice for covering peripheral IV catheter sites. Gauze dressings may increase the risk of contamination and do not provide a clear view of the site.

D. Adhesive bandage:
Adhesive bandages (commonly known as band-aids) are not suitable for covering peripheral IV catheter sites. They are typically used for small wounds or cuts.

A. Administer more than one pill to the client at a time. B. Tilt the client's head back when administering the medications C. Place the medications on the back of the client's tongue D. Mix the medications with a semisolid fop for the client

Correct Answer is D

Explanation

A. Administer more than one pill to the client at a time: Administering more than one pill at a time may increase the risk of choking, especially for individuals with dysphagia. It's generally advisable to administer one medication at a time to ensure proper swallowing.
B. Tilt the client's head back when administering the medications: Tipping the head backward can increase the risk of aspiration (inhalation of medication into the airways). It is recommended to keep the head in a neutral or slightly forward position to facilitate swallowing.
C. Place the medications on the back of the client's tongue: Placing medications on the back of the tongue may trigger the gag reflex and increase the risk of aspiration. Medications should be placed on the front of the tongue to allow for better control and coordination of swallowing.
D. Mix the medications with a semisolid food for the client (Correct Answer): Mixing medications with a semisolid food, often referred to as "food thickening," can be beneficial for clients with dysphagia. This helps make the medications easier to swallow and reduces the risk of choking or aspiration. However, it is important to check with the healthcare provider or pharmacist to ensure compatibility with specific medications.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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