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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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Morphine 2 mg IV: Morphine is a potent opioid analgesic commonly used to manage moderate to severe pain. However, in this scenario, the client reports pain as 5 on a scale of 0 to 10, which indicates moderate pain. Morphine 2 mg IV may be excessive for this level of pain and could result in unnecessary sedation, respiratory depression, or other opioid-related adverse effects. Therefore, it is not the most appropriate choice for managing the client's pain.

B) Amitriptyline 25 mg PO: Amitriptyline is a tricyclic antidepressant with analgesic properties, but it is not typically used as a first-line treatment for acute postoperative pain. Additionally, it is administered orally and may not provide rapid pain relief in the immediate postoperative period. Therefore, it is not the most suitable option for managing the client's pain after a total knee replacement surgery.

C) Ketorolac 15 mg IV: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that provides potent analgesic and anti-inflammatory effects. It is commonly used for the management of moderate to severe pain, including postoperative pain. In this scenario, the client reports moderate pain after total knee replacement surgery, making ketorolac an appropriate choice for pain management. Administering ketorolac 15 mg IV can provide effective pain relief without the sedative effects of opioids, making it the most suitable PRN medication for the client's pain level.

D) Acetaminophen 650 mg PO: Acetaminophen is a non-opioid analgesic commonly used for mild to moderate pain relief. While acetaminophen is generally safe and effective, it may not provide sufficient pain relief for a client who reports pain as 5 on a scale of 0 to 10 after total knee replacement surgery. Additionally, oral administration may result in delayed onset of action compared to IV medications. Therefore, acetaminophen 650 mg PO may not be the most optimal choice for managing the client's pain in this situation.

A. Grasp skin between thumb and forefinger throughout the injection. B. Aspirate the syringe prior to injecting the heparin. C. Use the Z-track method to administer the medication. D. Gently massage the site following the injection.

Correct Answer is A

Explanation

A) Grasp skin between thumb and forefinger throughout the injection: This is the correct answer. Grasping the skin between the thumb and forefinger creates tension, which helps to stabilize the tissue during the injection. This technique reduces the risk of tissue damage and minimizes bleeding following the injection of heparin subcutaneously.

B) Aspirate the syringe prior to injecting the heparin: Aspiration is not necessary for subcutaneous injections, as the risk of intravascular injection is minimal. Aspirating the syringe can increase discomfort for the client and is not recommended for subcutaneous injections.

C) Use the Z-track method to administer the medication: The Z-track method is used for intramuscular injections to minimize medication leakage into the subcutaneous tissue. However, heparin is typically administered subcutaneously, and the Z-track method is not appropriate for this route of administration.

D) Gently massage the site following the injection: Massaging the site following a subcutaneous injection of heparin can increase the risk of bleeding and hematoma formation. Therefore, this action should be avoided to minimize bleeding at the injection site.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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