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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Take the medication in the morning: Simvastatin is more effective when taken in the evening because cholesterol synthesis is higher at night. Taking it in the morning may reduce its lipid-lowering effect.
B. Report muscle tenderness: Muscle pain, tenderness, or weakness can indicate myopathy or rhabdomyolysis, serious adverse effects of statins. Clients should report these symptoms promptly for evaluation and possible medication adjustment.
C. This medication can cause kidney damage: Simvastatin primarily affects the liver and muscles. While rhabdomyolysis can indirectly impact kidney function, kidney damage is not a common direct effect of the medication.
D. Avoid drinking grapefruit juice for 3 hr after taking this medication: Grapefruit juice can inhibit metabolism of simvastatin, increasing the risk of toxicity. Avoiding grapefruit entirely, rather than timing it around the dose, is the recommended precaution.
Correct Answer is B
Explanation
A. "Be sure to sit when you urinate and double flush the toilet with the lid closed.": This instruction relates to precautions for clients taking medications that can be excreted in urine, such as certain chemotherapeutic agents, and is not relevant to methimazole therapy.
B. "Take precautions in crowds to avoid people who are ill.": Methimazole can cause agranulocytosis, leading to a decreased ability to fight infections. Clients should be advised to avoid large crowds and report symptoms like fever or sore throat promptly.
C. "It is important that you avoid contact with young children and pregnant people.": Methimazole does not require strict avoidance of these populations under normal circumstances, so this is not standard discharge teaching.
D. "Refrain from returning to work for the first few days of therapy.": Routine work restrictions are not necessary when starting methimazole unless the client experiences adverse effects such as severe fatigue or infection.
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