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 C
Explanation
Choice A rationale:
Providing samples for sputum cultures every 6 weeks is not a necessary instruction for a client with pulmonary tuberculosis. Sputum cultures are typically performed at specific intervals to monitor the progress of treatment and assess for bacterial resistance. This information is essential for healthcare providers but not for the client's daily care and safety.
Choice B rationale:
Consuming alcohol in moderation while taking antituberculosis medications is not recommended. Alcohol can interact with these medications and reduce their effectiveness. It is essential to advise the client to avoid alcohol completely while on tuberculosis treatment to ensure the best possible outcome.
Choice C rationale:
Wearing a mask while out or around crowds of people is a crucial precaution to prevent the spread of tuberculosis, which is highly contagious. Tuberculosis is transmitted through the air when an infected person coughs or sneezes, making mask-wearing an effective measure to protect both the client and others. This instruction promotes the safety of the client and the community.
Choice D rationale:
Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not a recommended practice. Infectious material should be properly disposed of in biohazard containers or bags designed for infectious waste. This instruction does not follow the standard safety protocols for managing infectious materials and is not in the best interest of the client's health.
Correct Answer is C
Explanation
Choice A rationale: Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
Choice B rationale: Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
Choice C rationale: Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
Choice D rationale: A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
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