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 B

Explanation

A. Potassium 4.2 mEq/L: While potassium levels should be monitored during amitriptyline therapy, the value of 4.2 mEq/L is within the normal range. There is no immediate concern based on this potassium level.

B. Total bilirubin 1.5 mg/dL

Amitriptyline, a tricyclic antidepressant, can sometimes cause hepatotoxicity, which may manifest as elevated liver enzymes or bilirubin levels. Therefore, any abnormality in liver function tests, such as total bilirubin, should be reported to the provider for further evaluation and management.

C. WBC count 5,000/mm³: The white blood cell count is not a commonly monitored parameter for amitriptyline, and the value of 5,000/mm³ is within the normal range. There is no immediate concern based on this WBC count.
D. Hct 44:The hematocrit (Hct) level is related to the percentage of red blood cells in the blood.A value of44%falls within the normal range for hematocrit. There’s no immediate concern related to amitriptyline use based on this result either.

A. "If I were you, I would get the vaccine to keep my family safe." B. "Influenza can be very serious to anyone who does not receive the vaccine." C. "The Influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form. D. The influenza vaccine is strongly encouraged, but I understand you would like to decline right now.

Correct Answer is D

Explanation

A. "If I were you, I would get the vaccine to keep my family safe:"
This statement imposes the nurse's personal opinion on the client and may not respect the client's autonomy and decision-making.
B. "Influenza can be very serious to anyone who does not receive the vaccine:"
While this statement conveys the seriousness of influenza, it may be perceived as coercive or fear-inducing. It is important to provide information without pressure.
C. "The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form:"
This statement is not accurate and may create unnecessary tension. Influenza vaccination is generally not mandatory, and clients have the right to decline without being labeled against medical advice for this particular vaccination.
D. "The influenza vaccine is strongly encouraged, but I understand you would like to decline right now:"
This is the correct answer. It acknowledges the client's decision to decline the vaccine while expressing that the vaccine is encouraged. It respects the client's autonomy and allows for open communication about the decision.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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