A nurse is assessing a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Distended neck veins
Elevated hematocrit level
Shortness of breath
Weight gain
The Correct Answer is B
A) Distended neck veins: Distended neck veins are typically associated with fluid volume excess rather than deficit. In heart failure, venous congestion can cause jugular venous distention, indicating fluid volume overload rather than deficit. Therefore, this finding would not suggest fluid volume deficit in a client with heart failure receiving furosemide.
B) Elevated hematocrit level: Fluid volume deficit, also known as dehydration or hypovolemia, is characterized by a loss of both water and electrolytes from the body, leading to a relative increase in the concentration of red blood cells and other blood components. This increase in concentration results in an elevated hematocrit level, which is a common laboratory finding in clients with fluid volume deficit. Furosemide, a loop diuretic, is commonly used to manage fluid overload in clients with heart failure by promoting diuresis and reducing excess fluid retention. However, excessive diuresis with furosemide can lead to fluid volume deficit if not adequately monitored and managed.
C) Shortness of breath: Shortness of breath is a common symptom of heart failure, particularly when fluid accumulates in the lungs (pulmonary edema) due to fluid volume overload. While shortness of breath may be present in both fluid volume deficit and excess, it is more commonly associated with fluid volume overload in clients with heart failure.
D) Weight gain: Weight gain is indicative of fluid volume excess rather than deficit. In heart failure, weight gain often occurs due to fluid retention, reflecting an increase in total body water and extracellular fluid volume. Monitoring weight is essential in managing heart failure and assessing fluid status, but weight gain would not suggest fluid volume deficit in a client receiving furosemide for heart failure management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Increased energy: While increased energy could be a positive outcome of treatment, it is not a specific indicator of the client's response to spironolactone therapy for’cirrhosis.
B) Decreased ascites: This is the correct answer. Spironolactone, a potassium-sparing diuretic, is commonly used to treat ascites in clients with cirrhosis by promoting diuresis and reducing fluid retention in the abdomen. Therefore, a decrease in ascites indicates a positive response to spironolactone therapy.
C) Increased appetite: Increased appetite is not typically a direct response to spironolactone therapy for cirrhosis. It may be influenced by various factors and is not specific to the client's response to the medication.
D) Decrea’ed jaundice: While spironolactone may indirectly help improve liver function, decrease fluid retention, and alleviate symptoms of cirrhosis, it is not primarily used to address jaundice. Other interventions and treatments may be necessary to manage jaundice in clients with liver cirrhosis.
Correct Answer is D
Explanation
A) Black stools: While black stools can be a potential side effect of gastrointestinal bleeding, it is not commonly associated with high-dose metoclopramide. This side effect is more commonly seen with medications such as aspirin or NSAIDs. Therefore, it is not the most pertinent adverse effect to monitor for with high-dose metoclopramide.
B) Dry cough: Dry cough is not a typical adverse effect of metoclopramide. Cough is more commonly associated with medications such as ACE inhibitors. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.
C) Oral candidiasis: While oral candidiasis (oral thrush) can occur as a side effect of some medications, it is not commonly associated with metoclopramide. Oral candidiasis is more frequently seen with corticosteroids or antibiotics. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.
D) Tardive dyskinesia: Tardive dyskinesia is a serious adverse effect associated with prolonged use of edicaopramide, especially at high doses. It is characterized by involuntary, repetitive movements of the face, tongue, or other parts of the body. Monitoring for signs and symptoms of tardive dyskinesia, such as repetitive facial grimacing or tongue protrusion, is crucial when administering high-dose metoclopramide to prevent this potentially irreversible condition. Therefore, this is the correct adverse effect to monitor for in clients receiving high-dose metoclopramide.
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