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?
Weight gain
Distended neck veins
Shortness of breath
Elevated hematocrit level
The Correct Answer is D
Choice A Reason:
Weight gain is incorrect. Weight gain is typically associated with fluid volume excess rather than deficit. In heart failure, fluid retention can lead to weight gain due to excess fluid accumulation in the body.
Choice B Reason:
Distended neck veins is incorrect. Distended neck veins are a sign of fluid volume excess, commonly seen in heart failure due to increased venous pressure and fluid retention.
Choice C Reason:
Shortness of breath is incorrect.: Shortness of breath is often associated with fluid accumulation in the lungs, known as pulmonary edema, which is a manifestation of fluid volume excess or fluid overload in heart failure.
Choice D Reason:
Elevated hematocrit level is correct. Furosemide is a diuretic that promotes diuresis (increased urine output), leading to fluid loss. When a client experiences fluid volume deficit or dehydration due to increased diuresis, there is a concentration of red blood cells in the blood, resulting in an elevated hematocrit level. This occurs because the blood becomes more concentrated when there's less fluid volume available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Weight loss is incorrect. While weight loss can be a side effect of citalopram, it's not typically considered a severe or urgent adverse effect that requires immediate reporting to the provider. It's more often observed in some individuals as a common side effect of this medication.
Choice B Reason:
Confusion can indicate a severe or uncommon adverse reaction to citalopram, especially in the context of treating major depression. It could potentially signify a serious condition that requires immediate attention. Reporting confusion promptly allows the healthcare provider to assess the situation and make appropriate adjustments to the medication regimen or provide additional interventions if necessary.
Choice C Reason:
Insomnia is incorrect. Insomnia is another potential side effect of citalopram. While it can affect the individual's quality of life, it's not typically an adverse effect that would be considered an urgent concern requiring immediate reporting to the provider.
Choice D Reason:
Bruxism is incorrect. Bruxism, or teeth grinding, is a less common side effect of citalopram. While it can cause discomfort or dental issues, it's not typically considered a priority adverse effect that necessitates immediate reporting to the provider compared to confusion, which might indicate a more serious or severe reaction.
Correct Answer is A
Explanation
Choice A Reason:
Apply the patch to a hairless area of the skin is correct. Nitroglycerin patches should be applied to a clean, hairless area of the skin to ensure proper absorption of the medication. Hair can interfere with the patch's adherence and the absorption of nitroglycerin into the bloodstream. The site chosen should be rotated to prevent skin irritation or tolerance development. Commonly used areas include the chest, upper arms, or torso, but it's important to follow specific instructions provided by the healthcare provider.
Choice B Reason:
Apply a 4x4 dressing over the patch is incorrect. Covering the nitroglycerin patch with a dressing may interfere with its absorption and effectiveness. These patches are designed to be applied directly to the skin without covering.
Choice C Reason:
Apply the patch to the same site every 24 hr is incorrect. Repeatedly applying the patch to the same site increases the risk of skin irritation or tolerance to the medication. It's crucial to rotate patch sites to avoid these issues.
Choice D Reason:
Apply the patch to a bony prominence on the chest is incorrect. Nitroglycerin patches should not be placed on bony prominences because these areas can be uncomfortable and may not provide optimal absorption. Instead, they are typically applied to relatively flat, hairless areas of the skin.
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