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) Ask another nurse if they are aware of potential interactions: Relying solely on another nurse's awareness of potential interactions is’not a comprehensive or reliable approach. Nurses may have varying levels of knowledge about medication interactions, and it's important to consult verified sources ’or accurate information.

B) Check the client's medical record for medication and food’interactions: While the client's medical record may contain information’about their current medications, it may not provide detailed information about potential interactions with specific foods or other medications. Additionally, relying solely on the medical record may not capture recent changes in medication or dietary intake.

C) Consult a drug reference guide for possible interactions: This is the correct action. Drug reference guides provide comprehensive information about medications, including potential interactions with other drugs and food. Nurses can access reliable drug reference guides to ensure they have accurate information before administering medications.

D) Have the client take the medication on an empty stomach to avoid interactions: Instructing the client to take medication on an empty stomach without knowledge of specific interactions could be inappropriate and potentially harmful. Some medications require administration with food to enhance absorption or reduce gastrointestinal side effects. It's essential to consult reliable sources ’o determine the appropriate administration instructions for each medication.

A. "You should not feel anything more than a minor sting from the injection." B. "You must take this medication because there is no other option to treat this infection." C. "Refusing the injection means you will not get better." D. "I will discuss other treatments options with your provider."

Correct Answer is D

Explanation

A) "You should not feel anything more than a minor sting from the injection."
While this statement aims to reassure the client about the pain associated with the injection, it does not address the client's fear of needles or provide an alternative solution for medication administration. Therefore, it is not the most appropriate response in this situation.

B) "You must take this medication because there is no other option to treat this infection."
This response may increase the client's anxiety and resistance to receiving the medication. It fails to acknowledge the client's fear and does not offer a supportive approach to addressing the refusal. Additionally, there may be alternative treatment options available, making this statement inaccurate and potentially alarming for the client.

C) "Refusing the injection means you will not get better."
This response is confrontational and may further escalate the client's anxiety and resistance. It does not acknowledge or address the client's fear of needles, nor does it provide an alternative solution for medication administration. Using fear as a tactic to coerce the client into accepting the injection is not therapeutic and undermines the nurse-client relationship.

D) "I will discuss other treatment options with your provider."
This response acknowledges the client's fear and refusal of the injection while also demonstrating a commitment to finding alternative solutions for medication administration. By involving the healthcare provider in the discussion, the nurse can explore alternative treatment options that do not involve injections, such as oral medications or topical treatments. This approach respects the client's autonomy and promotes collaboration in decision-making, leading to a more positive and effective outcome for the client's care. Therefore, this is the most appropriate response in this situation.

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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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