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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should include the statement, "Lifelong treatment with this medication is necessary.”. This is because rifampin is often part of a multidrug regimen used to treat tuberculosis, and treatment typically lasts for several months, sometimes up to a year. It is crucial for the client to understand the need for long-term treatment to ensure the successful eradication of the tuberculosis bacteria from their system.

Choice B rationale:

The statement, "The medication causes amenorrhea if taken along with an oral contraceptive," is not accurate. Rifampin is known to interact with oral contraceptives, decreasing their effectiveness, but it does not directly cause amenorrhea. The correct teaching should focus on the need for alternative or additional contraceptive methods while taking rifampin.

Choice C rationale:

The statement, "You should wear glasses instead of contacts while taking this medication," is not directly related to rifampin. Rifampin can cause certain ocular side effects, but it does not necessarily require the client to switch from contacts to glasses. This advice would depend on the individual's eye health and any specific concerns.

Choice D rationale:

The statement, "A yellow tint to the skin is an expected reaction to the medication," is incorrect. While rifampin can cause a harmless side effect of orange-red discoloration of body fluids, such as urine, sweat, and tears, it does not typically cause a yellow tint to the skin. The nurse should clarify this misconception with the client.

A. Withhold the digoxin dose for decreased heart rate. B. Administer digoxin 0.25 mg. C. Administer digoxin 0.125 mg. D. Withhold the digoxin dose for elevated BP. .

Correct Answer is A

Explanation

Choice A rationale:

Withholding the digoxin dose for a decreased heart rate is the correct action. Digoxin is a medication used to treat heart failure, but it can lead to bradycardia (slow heart rate) as a side effect. In this scenario, the client's heart rate is already at 54 beats per minute, which is below the normal range. Administering digoxin could further slow the heart rate, potentially leading to dangerous bradycardia or heart block. Withholding the medication is essential to prevent this adverse event.

Choice B rationale:

Administering digoxin 0.25 mg is not the appropriate action in this case. The client's heart rate is already below the normal range, and giving the full dose of digoxin could further depress the heart rate and increase the risk of bradycardia. Withholding the medication is the safer course of action.

Choice C rationale:

Administering digoxin 0.125 mg is not recommended because the client's heart rate is already below the normal range. While a reduced dose may be considered in some situations, it's essential to withhold the medication and consult with the healthcare provider in this specific case, as the client's heart rate is significantly low.

Choice D rationale:

Withholding the digoxin dose for elevated BP is not the appropriate action. Digoxin is primarily used to treat heart failure by increasing the force of cardiac contractions. Elevated blood pressure is not an indication to withhold digoxin. The focus should be on addressing the low heart rate in this scenario. .

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis.Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for digoxin 0.25 mg P.O. daily for heart failure.The client's current vital signs are: BP 144/96, heart rate 54/min, respirations 18/min, and temperature 37°C (98.6°F). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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