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 A
Explanation
A. Hydromorphone: This is a potent opioid analgesic and is commonly used for the management of severe pain, especially in cancer patients. It provides strong pain relief and is often used in situations where other pain medications are not sufficient.
B. Aspirin: Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) with anti-inflammatory and analgesic properties. While it may be used for pain relief in some situations, it is not typically the first choice for severe pain in pancreatic cancer.
C. Acetaminophen (Caldoler): Acetaminophen is a non-opioid analgesic and antipyretic. It is not as potent as opioids and may not be sufficient for managing severe pain, especially in the context of advanced cancer.
D. Meloxicam: Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) and is not the first-line choice for severe pain, particularly in cancer patients. Opioid analgesics are generally preferred for managing severe pain in cancer.
Correct Answer is B
Explanation
A. "Lie down for 1 hour after administering the medication.": This statement is not necessary for nasal cyanocobalamin administration. There is no need for the client to lie down for an extended period after administering the medication.
B. "Administer the medication into one nostril once per week.": This is the correct information. Nasal cyanocobalamin is typically administered once a week for the treatment of pernicious anemia. It's important for the nurse to emphasize the correct frequency and route of administration to ensure the effectiveness of the treatment.
C. "Plan to self-administer this medication for the next 6 months.": The duration of treatment may vary based on the healthcare provider's prescription. The nurse should instruct the client based on the specific instructions provided by the healthcare provider rather than a predetermined time frame.
D. "Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose.": This statement is not a standard recommendation for nasal cyanocobalamin administration. If the client has concerns about a stuffy nose, they should consult with their healthcare provider rather than using a nasal decongestant without guidance.
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