A nurse is caring for a client who has fluid volume excess. Which of the following manifestations should the nurse expect?

Bounding pulse

Polyuria

Weight loss

Dry mucous membranes

Answer and Explanation

The Correct Answer is A

Rationale

A. Bounding pulse: A full, strong, or bounding pulse is a classic sign of fluid volume excess due to increased circulating blood volume. The elevated intravascular pressure causes the heart to eject blood more forcefully, making the pulse more palpable. Assessing pulse quality helps identify hypervolemia and monitor cardiovascular status.

B. Polyuria: Polyuria is more commonly associated with fluid volume excess caused by conditions like diabetes insipidus or use of diuretics, but it is not a primary manifestation in general hypervolemia. Fluid overload typically results in edema and decreased urinary output if the kidneys are unable to compensate.

C. Weight loss: Weight loss indicates fluid volume deficit rather than excess. Fluid retention in hypervolemia usually presents as rapid weight gain, which reflects increased total body water and extracellular fluid accumulation. Monitoring daily weight is key to assessing fluid status.

D. Dry mucous membranes: Dry mucous membranes are characteristic of dehydration or fluid volume deficit. In fluid volume excess, mucous membranes may appear moist, and edema may be present due to fluid accumulation in tissues. Evaluating mucous membranes helps differentiate between overhydration and dehydration.

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Correct Answer is C

Explanation

Rationale

A. Apply an abduction pillow to the legs: An abduction pillow is used to maintain proper hip alignment, especially after hip surgery, but it does not prevent plantar flexion contractures. Its purpose is to keep the lower extremities in proper abduction rather than address ankle mobility.

B. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip in immobile clients but does not influence ankle positioning. While important for hip alignment, it does not prevent plantar flexion contractures of the feet.

C. Use foot splints: Foot splints (or ankle-foot orthoses) maintain the feet in a neutral position, preventing plantar flexion and subsequent contracture. Regular use supports joint flexibility, reduces muscle shortening, and helps preserve functional mobility in immobile clients.

D. Prop the feet up: Elevating the feet may relieve pressure and promote circulation, but it can allow the toes to point downward and contribute to plantar flexion over time. This method is not effective in preventing contractures and may worsen the problem if used as the sole intervention.

A. Fold the existing patch on itself and dispose of it in a childproof container. B. Shave the client's lower leg for placement of the new patch. C. Discard the old patch and apply a new one in the same location. D. Keep the existing patch on and place the new patch in a different location.

Correct Answer is A

Explanation

Rationale

A. Fold the existing patch on itself and dispose of it in a childproof container: Folding the patch so the adhesive sides stick together prevents accidental exposure to medication, which could harm others. Proper disposal in a secure container ensures safety and prevents accidental ingestion or contact, especially for potent medications like opioids or nitroglycerin.

B. Shave the client's lower leg for placement of the new patch: Shaving is unnecessary unless hair significantly interferes with adhesion. Using razors can cause microabrasions, increasing the risk of skin irritation or infection. Hair can usually be trimmed with scissors instead of shaving.

C. Discard the old patch and apply a new one in the same location: Applying a new patch to the same site can cause skin irritation or burns due to repeated exposure. Rotation of application sites is necessary to allow the skin to recover and to maintain patch efficacy.

D. Keep the existing patch on and place the new patch in a different location: Leaving the old patch in place results in double dosing, which can lead to toxicity. All transdermal patches should be removed before applying a new one to prevent accidental overdose.

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A nurse is caring for a client who has fluid volume excess. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures?

Correct Answer is C

Explanation

A nurse is preparing to administer a transdermal patch to a client. The nurse notes the client already has a patch that was applied 24 hr ago. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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