A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

Pyuria

Weight loss

Jugular vein distention

Muscle contractions

Answer and Explanation

The Correct Answer is C

Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.

Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.

Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.

Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.

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Correct Answer is C

Explanation

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

A. Increased thirst and dry mucous membranes B. Low blood pressure and increased heart rate C. Difficulty breathing and weight gain D. Dry cough and poor skin turgor

Correct Answer is C

Explanation

Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.

Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.

Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

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A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

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