A nurse is assessing a client who has a continuous IV infusion. The nurse should identify that which of the following findings is a manifestation of fluid overload?
Elevated blood pressure
Decreased pulse rate
Decreased gastrointestinal motility
Flattened neck veins
The Correct Answer is A
A. Elevated blood pressure: Excess fluid in the vascular system increases circulating volume, which raises blood pressure. This is a common early sign of fluid overload and can lead to additional complications if not addressed promptly.
B. Decreased pulse rate: Fluid overload typically causes an increased pulse rate as the heart works harder to manage the extra volume. A decreased pulse is not a usual manifestation of fluid overload.
C. Decreased gastrointestinal motility: Fluid overload does not directly reduce gastrointestinal motility. Bowel slowing is more commonly associated with medications, immobility, or other systemic conditions rather than excess IV fluid.
D. Flattened neck veins: Fluid overload usually causes distended neck veins due to increased central venous pressure. Flattened neck veins suggest hypovolemia or low circulating blood volume rather than overload.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loss of consciousness: Adenosine can cause transient lightheadedness or dizziness, but complete loss of consciousness is not an expected effect during administration. Any syncope would be brief and uncommon.
B. Conversion of atrial fibrillation: Adenosine is effective for terminating paroxysmal supraventricular tachycardia (PSVT) but does not convert atrial fibrillation or atrial flutter. Its action is specific to AV node–dependent reentrant tachycardias.
C. Increased heart rate: Adenosine typically slows conduction through the AV node and may transiently slow the heart rate. An increase in heart rate is not an expected pharmacologic effect.
D. A period of asystole: Adenosine briefly blocks AV nodal conduction, which can result in a transient period of asystole lasting a few seconds. This effect is anticipated and resolves quickly, restoring normal sinus rhythm in PSVT.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationales for Correct Choices
- Not take the antacid within 30 min of the sucralfate: Antacids can interfere with the absorption and adherence of sucralfate to the gastric mucosa. Spacing administration by at least 30 minutes ensures optimal therapeutic action of both medications.
- Shake the suspension thoroughly before administration: Sucralfate is a suspension, meaning its medication particles are dispersed in a liquid. To ensure the client receives the correct, full dose and therapeutic effect, the medication must be shaken well immediately before measuring and administering.
Rationale for Incorrect Choices:
- Discontinue the sucralfate as soon as ulcer manifestations subside: Stopping sucralfate too early can prevent complete healing of the ulcer. Full courses should be completed as prescribed.
- Take the sucralfate with meals: Sucralfate should be taken on an empty stomach (at least 1hour before meals and at bedtime) to allow it to form the protective barrier on the ulcer before food and acid production increase.
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