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

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 C

Explanation

A) A client vomits after receiving an oral medication: While vomiting after medication administration should be documented in the client's medical record as it could indicate a ’otential adverse reaction or medication intolerance, it does not necessarily require an incident report unless there are unusual circumstances surrounding the event.

B) A client receives their meal tray 20 minutes before time: This situation does not require an incident report. It may be considered a minor deviation from the usual mealtime schedule, and no harm or adverse outcome is implied.

C) A client receives their insulin before scheduled time: This is the correct answer. Administering insulin before the scheduled time can pose significant risks to the client, potentially leading to hypoglycemia or other adverse effects. Such deviations from the prescribed administration time should be documented in an incident report to ensure appropriate investigation and prevention of recurrence.

D) A client experiences a seizure: While a client experiencing a seizure is a critical event that requires immediate nursing intervention and documentation, it does not typically warrant an incident report unless it occurs in unusual circumstances or if there are concerns about the client's safety or well-being during the seizur’.

A. A child who recently received the human papillomavirus vaccine B. An older adult client living in a long-term care facility C. A client who has AIDS D. A young adult who has an allergy to eggs

Correct Answer is C

Explanation

A) A child who recently received the human papillomavirus vaccine: There is no contraindication for administering the varicella vaccine to a child who recently received the human papillomavirus vaccine. These vaccines target different viruses and can typically be given concurrently without issue.

B) An older adult client living in a long-term care facility: Older adults living in long-term care facilities are at increased risk of complications from varicella infection and are, therefore, recommended to receive the varicella vaccine unless contraindicated due to specific health conditions.

C) A client who has AIDS: Clients with AIDS or other severe immunosuppressive conditions should not receive live virus vaccines like the varicella vaccine due to the risk of vaccine-induced disease. These individuals may have compromised immune systems, increasing the risk of adverse reactions or inadequate immune response to the vaccine.

D) A young adult who has an allergy to eggs: While some vaccines, including the varicella vaccine, are grown in eggs, having an allergy to eggs is not an absolute contraindication for receiving the vaccine. Most individuals with egg allergies can safely receive the varicella vaccine under medical supervision, as the risk of an allergic reaction is low.

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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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