A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?
Increased thirst and dry mucous membranes
Low blood pressure and increased heart rate
Difficulty breathing and weight gain
Dry cough and poor skin turgor
The Correct Answer is C
Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.
Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.
Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement does not suggest that further health education is necessary. The client is expressing a realistic concern about the cost of the medication, which may be expensive or not covered by insurance. The nurse should acknowledge the client's financial situation and provide information about possible assistance programs or alternative options.
Choice B reason: This statement does not suggest that further health education is necessary. The client is expressing a reasonable anxiety about the medication, which may have side effects or interactions that require monitoring. The nurse should reassure the client and explain the purpose and frequency of the blood tests, as well as the potential benefits and risks of the medication.
Choice C reason: This statement does not suggest that further health education is necessary. The client is expressing a sense of wonder or skepticism about the medication, which may be uncommon or novel for the treatment of obesity. The nurse should educate the client about how the medication works and what to expect from the treatment, as well as the evidence and research behind it.
Choice D reason: This statement suggests that further health education is necessary. The client is expressing a false or unrealistic expectation about the medication, which is not a magic pill or a substitute for lifestyle changes. The nurse should correct the client and emphasize the importance of following a healthy diet and exercise regimen, as well as the goals and limitations of the medication.
Correct Answer is A
Explanation
Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.
Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.
Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.
Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.
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