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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Urinary output: Confusion and pitting edema can be signs of fluid overload, a potential complication of TPN administration. Assessing urinary output can help determine if the client is experiencing fluid overload by evaluating the kidneys' ability to excrete excess fluid. Decreased urinary output may indicate renal impairment or inadequate fluid elimination, which can exacerbate fluid overload and contribute to symptoms such as confusion and edema.

B) Blood glucose level: Monitoring blood glucose levels is important in clients receiving TPN, especially if they have diabetes or are at risk of hyperglycemia due to TPN's high glucose content. However, in this scenario, the client's symptoms of confusion and pitting edema suggest a more immediate concern related to fluid status rather than glucose regulation.

C) Weight: Monitoring weight is essential in assessing fluid balance and detecting changes in hydration status. However, assessing weight may not provide immediate information on the client's current fluid overload status. While weight changes over time can indicate fluid retention or loss, assessing urinary output is more direct in evaluating the client's response to slowing the TPN infusion rate.

D) Heart rate: Changes in heart rate can occur in response to fluid volume overload or dehydration. However, assessing heart rate may not provide immediate information on the client's current fluid status. Monitoring heart rate is important in assessing cardiovascular function but may not be the most relevant assessment immediately after slowing the TPN infusion rate in a client with signs of fluid overload

A. WBC count B. INR C. BUN D. Potassium level

Correct Answer is A

Explanation

A) WBC count: Filgrastim is a granulocyte colony-stimulating factor (G-CSF) medication used to stimulate the production of white blood cells (WBCs), particularly neutrophils, in individuals with neutropenia. Therefore, monitoring the WBC count is essential to evaluate the effectiveness of filgrastim therapy. An increase in WBC count indicates a response to treatment, helping to prevent or manage neutropenic complications such as infections.

B) INR: The international normalized ratio (INR) is a laboratory test used to monitor the effectiveness of anticoagulant therapy, particularly warfarin (Coumadin). It measures the clotting ability of the blood and is not directly related to filgrastim therapy. Therefore, monitoring the INR is not appropriate for evaluating the effectiveness of filgrastim treatment.

C) BUN: Blood urea nitrogen (BUN) is a laboratory test used to assess kidney function and hydration status. It measures the concentration of urea nitrogen in the blood and is not directly related to filgrastim therapy. Monitoring BUN levels may be indicated for assessing renal function in certain clinical contexts but is not specific to evaluating the effectiveness of filgrastim treatment.

D) Potassium level: Monitoring potassium levels is important for assessing electrolyte balance and kidney function but is not directly related to filgrastim therapy. Potassium levels may be affected by various factors, including medications, diet, and renal function. However, they do not directly reflect the effectiveness of filgrastim in stimulating WBC production.

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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?

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