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","C"]

Explanation

A. Absence of deep-tendon reflexes:
Absence of deep-tendon reflexes is a sign of magnesium toxicity. Magnesium sulfate, when infused in high doses, can lead to neuromuscular blockade and affect reflexes. Discontinuing the infusion and administering calcium gluconate can counteract the effects of magnesium.

B. Urine output 80 mL in 4 hours:
Urine output is not a direct indicator of magnesium toxicity. Monitoring urine output is important for assessing renal function, but it is not a specific sign of magnesium toxicity.

C. Decreased level of consciousness:
Decreased level of consciousness is another sign of magnesium toxicity. Central nervous system depression is a potential adverse effect of elevated magnesium levels. Administering calcium gluconate can help antagonize the effects of magnesium.

D. Report of chills:
Chills are not typically associated with magnesium toxicity. This symptom may indicate other issues, such as infection or discomfort.
E. Systolic blood pressure 130 mm/Hg:
Systolic blood pressure within a normal range is not a sign of magnesium toxicity. Blood pressure changes are not typically the primary indicators of magnesium toxicity.

A. Urine specific gravity 1.020 B. BUN 28 mg/dl C. Serum hematocrit 55% D. Serum osmolarity 310 mOsm

Correct Answer is D

Explanation

A. Urine specific gravity 1.020: While this value indicates concentrated urine and can be useful in assessing dehydration, it doesn’t specifically confirm effective treatment. High urine specific gravity suggests dehydration because the kidneys are conserving water, but it doesn’t directly confirm the effectiveness of treatment.
B. BUN 28 mg/dl (Blood Urea Nitrogen): Elevated BUN levels can be seen in dehydration, but it's not a direct marker of effective treatment. It indicates dehydration due to increased urea concentration in the blood but doesn’t confirm if the treatment has been effective or not.
C. Serum hematocrit 55%: In dehydration, the blood becomes more concentrated due to water loss, causing an increase in hematocrit levels. However, while this value might indicate dehydration initially, it may not specifically confirm the effectiveness of treatment once initiated.
D. Serum osmolarity 310 mOsm: Serum osmolarity measures the concentration of particles in the blood. In dehydration, the blood becomes more concentrated, leading to increased serum osmolarity. When treatment is effective, rehydration occurs, diluting the blood and bringing serum osmolarity back toward normal levels. Therefore, a decrease in serum osmolarity towards the normal range (280-300 mOsm) would indicate effective treatment of dehydration

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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

A nurse is caring for a client who is receiving a continuous IV infusion of magnesium sulfate for preterm labor. The nurse should discontinue the infusion and prepare to administer calcium gluconate if the client demonstrates which of the following findings? (Select all that apply.

Correct Answer is ["A","C"]

Explanation

A nurse is teaching a class about administering IV fluids to treat dehydration. The nurse should include in the teaching that which of the following laboratory values indicates effective treatment of dehydration?

Correct Answer is D

Explanation

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