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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Calling the doctor for more antiemetic medication is not the best intervention for the nurse to facilitate. Antiemetics are drugs that prevent or reduce nausea and vomiting, but they may have side effects such as drowsiness, dry mouth, or constipation. The nurse should first try non-pharmacological measures to relieve the patient's nausea, such as giving small sips of water, providing a cool and quiet environment, or using aromatherapy.

Choice B reason: Giving the patient small sips of tepid water is the best intervention for the nurse to facilitate. Water can help hydrate the patient and dilute any stomach acid that may cause irritation. Tepid water is water that is slightly warm, which can be more soothing than cold or hot water. Small sips can prevent the patient from swallowing too much air, which can worsen nausea and vomiting.

Choice C reason: Helping the patient lay supine is not a good intervention for the nurse to facilitate. Supine means lying flat on the back, which can increase the risk of aspiration, or inhaling food or fluids into the lungs. Aspiration can cause pneumonia, a serious lung infection. The nurse should help the patient lay on their side, with their head elevated, to prevent aspiration and reduce pressure on the stomach.

Choice D reason: Showing the patient how to use the patient-controlled analgesia is not a relevant intervention for the nurse to facilitate. Patient-controlled analgesia is a system that allows the patient to self-administer pain medication through an IV pump. It has nothing to do with nausea and vomiting, and may even cause them as side effects. The nurse should monitor the patient's pain level and adjust the analgesia settings as needed, but not as a way to treat nausea.

A. Dark-colored stools B. Constipation C. Nausea D. Abdominal pain

Correct Answer is A

Explanation

Choice A reason: Dark-colored stools are an adverse effect of orlistat, a medication that blocks the absorption of fat in the intestines. The unabsorbed fat can cause the stools to become oily, foul-smelling, and dark in color. This can indicate a serious condition called steatorrhea, which can lead to malnutrition and vitamin deficiencies.

Choice B reason: Constipation is not an adverse effect of orlistat. In fact, orlistat can cause the opposite problem of diarrhea, especially if the client consumes too much fat in their diet. Constipation may be caused by other factors, such as dehydration, lack of fiber, or medication side effects.

Choice C reason: Nausea is not an adverse effect of orlistat. Nausea may be a symptom of other conditions, such as gastritis, gastroenteritis, or pregnancy. Nausea may also be caused by other medications, such as antibiotics, opioids, or chemotherapy drugs.

Choice D reason: Abdominal pain is not an adverse effect of orlistat. Abdominal pain may be a sign of other conditions, such as appendicitis, gallstones, or kidney stones. Abdominal pain may also be caused by other medications, such as NSAIDs, steroids, or oral contraceptives.

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