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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. "Take the medication with an antacid if it upsets your stomach."
Explanation: Antacids may interfere with the absorption of iron. It is generally recommended to take iron supplements on an empty stomach or with vitamin C-containing foods to enhance absorption.
B. "Stop taking the medication if your stools become green or black."
Explanation: Ferrous sulfate can cause stools to become dark green or black, which is a normal and expected side effect. However, excessive black, tarry stools may indicate gastrointestinal bleeding and should be reported to the healthcare provider.
C. "Drink the elixir using a straw to prevent staining your teeth."
Explanation: Ferrous sulfate elixir can stain the teeth. Using a straw helps bypass direct contact with the teeth, reducing the risk of staining.
D. "Increase your fiber intake to prevent constipation."
Explanation: Iron supplements, including ferrous sulfate, can cause constipation. Increasing fiber intake can help alleviate constipation.
E. "Increase your intake of dairy products to increase the absorption of this medication."
Explanation: Calcium-containing foods, such as dairy products, can inhibit the absorption of iron. It is advisable to take iron supplements separately from calcium-containing foods.
Correct Answer is B
Explanation
A. "You should take this medication on an empty stomach:"
Bumetanide can be taken with or without food. It is not necessary to take it on an empty stomach.
B. "You should monitor for hearing difficulties:"
This is the correct answer. Loop diuretics, including bumetanide, are associated with ototoxicity, which can lead to hearing difficulties or hearing loss. Clients should be instructed to report any changes in hearing.
C. "You should decrease your intake of foods high in potassium:"
Bumetanide can cause potassium loss, but instructing the client to decrease potassium intake may not be appropriate without knowing the client's specific potassium levels. Monitoring potassium levels and adjusting the diet or prescribing supplements as needed would be a more individualized approach.
D. "You should take the medication at bedtime:"
Bumetanide is often prescribed in the morning to avoid disrupting sleep with increased urination during the night. Taking it at bedtime is not a typical recommendation.
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