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 is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
Correct Answer is B
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client should avoid alcohol and other substances that can harm the liver, as adalimumab can increase the risk of liver toxicity and hepatitis.
Choice B reason: This is a statement that indicates a need for further teaching. The client should not take naproxen and aspirin as needed for pain relief, as these are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding and gastrointestinal ulcers. Adalimumab can also increase the risk of bleeding and ulcers, as it suppresses the immune system and the inflammatory response.
Choice C reason: This is not a statement that indicates a need for further teaching. The client should report any signs of infection or fever to the doctor, as adalimumab can increase the risk of serious infections and sepsis. Adalimumab can also mask the symptoms of infection, such as inflammation and pain.
Choice D reason: This is not a statement that indicates a need for further teaching. The client should inject the medication under the skin of the abdomen or thigh, as this is the recommended route and site for adalimumab administration.
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