A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

Decreased bowel sounds

Urine output of 360 mL/12 hr

Blood pressure of 100/74 mm Hg

Distended neck veins

Answer and Explanation

The Correct Answer is D

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

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Correct Answer is D

Explanation

A. Increased senses: PCA pump use, typically involving opioids, does not heighten the senses. Instead, opioids often dull sensory perception and can cause sedation rather than making sensations sharper or more intense.

B. Decreased sleep: Opioids used in PCA pumps often promote drowsiness and sleep rather than reducing it. Sleep disturbances are not a common direct effect of properly managed PCA analgesia unless pain remains uncontrolled.

C. Difficulty swallowing: Difficulty swallowing is not a usual side effect associated with PCA use. If it occurs, it would likely suggest another issue, such as a neurological problem, rather than a typical reaction to PCA-administered opioids.

D. Urinary frequency: Opioids can affect the bladder by either causing urinary retention or, less commonly, altering normal patterns. Clients receiving adequate hydration and pain management might experience urinary frequency, especially as mobility increases postoperatively.

A. Administer aspirin for fever B. Apply cooling blanket C. Monitor vital signs every 4 hours D. Place client on telemetry E. Palpate thyroid area to assess for hematoma

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

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A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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