A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).
Crackles in lung bases.
Periorbital edema.
Swelling at the IV site.
Bounding radial pulse.
Flat neck veins when supine.
Correct Answer : A,B,D
Choice A rationale:
Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.
Choice B rationale:
Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.
Choice D rationale:
Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.
Choice C rationale:
Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.
Choice E rationale:
Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Captopril.
Choice A: Captopril Captopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat conditions like high blood pressure and heart failure. One of the common side effects of ACE inhibitors is a persistent, non-productive cough. This cough occurs due to the accumulation of bradykinin, a potent peptide that can induce coughing.
Choice B: Metoprolol Metoprolol is a beta-blocker used to treat high blood pressure and heart failure. Common side effects include dizziness, slow or irregular heartbeat, and unusual tiredness or weakness. However, it is not typically associated with a non-productive cough.
Choice C: Furosemide Furosemide is a loop diuretic used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder. While it can cause side effects like diarrhea, constipation, and loss of appetite, a non-productive cough is not a typical side effect of Furosemide.
Choice D: Digoxin Digoxin is used to treat heart failure and irregular heartbeat. Common side effects include dizziness, slow or irregular heartbeat, and unusual tiredness or weakness. However, a non-productive cough is not a typical side effect of Digoxin.
Correct Answer is D
Explanation
Choice A rationale:
A respiratory rate of 9/min and shallow respirations are indicative of hypoventilation, which can lead to an accumulation of carbon dioxide (CO2) in the blood. This condition results in respiratory acidosis (Choice D). In respiratory acidosis, the arterial pH is decreased (acidic) while the PaCO2 (partial pressure of carbon dioxide) is elevated.
Choice B rationale:
Respiratory alkalosis (Choice B) is characterized by a low PaCO2 and an elevated pH due to hyperventilation. Shallow respirations and a respiratory rate of 9/min do not align with this condition, as it typically involves rapid and deep breathing.
Choice C rationale:
Metabolic alkalosis (Choice C) results from a primary excess of bicarbonate (HCO3-) in the blood and is not associated with the given respiratory patterns. Shallow respirations and a low respiratory rate are more likely to lead to an accumulation of CO2, causing respiratory acidosis (Choice D).
Choice D rationale:
The correct answer is choice D. Shallow respirations and a respiratory rate of 9/min indicate hypoventilation, leading to an accumulation of CO2 in the blood. This condition results in respiratory acidosis, where the arterial pH is decreased. The body's compensatory response is to retain bicarbonate to normalize pH, but this can result in an elevated HCO3- level. The primary acid-base imbalance in this case is respiratory acidosis. .
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