A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?
Pyuria
Weight loss
Jugular vein distention
Muscle contractions
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a correct answer because 0.9% Sodium Chloride is an isotonic solution, which means it has the same osmolarity as the blood plasma. It does not cause any fluid shifts between the intracellular and extracellular compartments.
Choice B reason: This is not a correct answer because Lactated Ringer's is an isotonic solution, which means it has the same osmolarity as the blood plasma. It does not cause any fluid shifts between the intracellular and extracellular compartments.
Choice C reason: This is not a correct answer because D5W (5% Dextrose in Water) is an isotonic solution when it is in the IV bag, but it becomes hypotonic once it enters the body, as the dextrose is rapidly metabolized and only water remains. However, it is not a preferred solution for a patient with critically high sodium, as it can cause cerebral edema and worsen the neurological status.
Choice D reason: This is a correct answer because 0.45% Sodium Chloride is a hypotonic solution, which means it has a lower osmolarity than the blood plasma. It causes fluid to shift from the extracellular to the intracellular compartment, which can help lower the sodium level and correct the fluid imbalance.
Correct Answer is C
Explanation
Choice A reason: This is not a correct finding for hypervolemia. Hypotension is a low blood pressure, which can be caused by hypovolemia (low blood volume) or other factors. Hypervolemia is an excess of fluid in the body, which can increase the blood pressure.
Choice B reason: This is not a correct finding for hypervolemia. Bradycardia is a slow heart rate, which can be caused by heart block, medication, or other factors. Hypervolemia can cause tachycardia (fast heart rate) as the heart tries to pump the excess fluid.
Choice C reason: This is a correct finding for hypervolemia. Peripheral edema is a swelling of the extremities due to fluid accumulation in the tissues. Hypervolemia can cause peripheral edema as the fluid leaks from the blood vessels into the interstitial spaces.
Choice D reason: This is not a correct finding for hypervolemia. Weight loss is a decrease in body weight, which can be caused by dehydration, malnutrition, or other factors. Hypervolemia can cause weight gain as the body retains more fluid.
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