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 C

Explanation

A. A vein that feels hard to the touch:
A vein that feels hard to the touch may indicate thrombosis or inflammation and is not a suitable site for catheter insertion.
B. A vein in the client's dominant arm:
The choice of arm may depend on the client's preference, but it is not a strict rule. The nurse can choose a suitable vein in either arm based on factors such as accessibility and vein condition.
C. A vein proximal to the previous site:
This is the correct answer. Placing the catheter proximal (above or upstream) to the previous site helps minimize the risk of complications such as infiltration and thrombophlebitis at the new site. It allows for optimal vein health and reduces the likelihood of complications associated with repeated punctures in the same area.
D. A vein on the client's wrist:
Veins on the wrist may be smaller and more prone to complications. It is generally recommended to choose larger, more accessible veins for catheter insertion.

A. Cover the medication on the client's skin with a sterile gauze pad. B. Spread the medication over a 12.7 cm (5 in) area of the client's skin, C. Measure the dosage of medication using the applicator paper D. Apply the medication to the same site for three consecutive days

Correct Answer is B

Explanation

A. Cover the medication on the client's skin with a sterile gauze pad:
Nitroglycerin ointment is typically applied directly to the skin, and covering it with a sterile gauze pad is not a common practice. The ointment is absorbed through the skin.
B. Spread the medication over a 12.7 cm (5 in) area of the client's skin:
This is the correct answer. Nitroglycerin ointment is usually applied to a specific area of the skin, and the recommended area is often around 12.7 cm (5 inches). The nurse should spread the ointment evenly over this specified area.
C. Measure the dosage of medication using the applicator paper:
Nitroglycerin ointment is typically measured using a dosing strip or measuring paper provided with the medication. Using the applicator paper to measure the appropriate dosage is a common practice.
D. Apply the medication to the same site for three consecutive days:
Nitroglycerin ointment is often rotated to different sites to prevent local irritation or tolerance. It is not typically applied to the same site for three consecutive days.

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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

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