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 C
Explanation
Choice A Reason:
Ondansetron is incorrect. Ondansetron is an anti-nausea medication commonly used in cancer patients to manage nausea and vomiting, often caused by chemotherapy. It's not typically contraindicated or known to interact significantly with morphine administered via a PCA pump. This combination is often used to manage both pain and associated symptoms in cancer patients.
Choice B Reason:
Acetaminophen is incorrect. Acetaminophen is a pain reliever and fever reducer that doesn't typically interact significantly with morphine administered via a PCA pump. It's often used concurrently with other pain medications to manage discomfort in cancer patients. There isn't a known significant interaction between acetaminophen and morphine when used appropriately.
Choice C Reason:
Nalbuphine is correct. Nalbuphine is an opioid analgesic, similar to morphine, and administering it concurrently with morphine could potentially lead to opioid overdose or increased risk of opioid-related side effects such as respiratory depression. Thus, it's crucial to clarify with the provider whether there might be a potential interaction or if both medications are indeed necessary in this specific clinical scenario.
Choice D Reason:
Insulin glargine is incorrect. Insulin glargine is a long-acting insulin used to manage blood sugar levels in individuals with diabetes. While its interaction with morphine isn't typically a concern, it's essential to monitor blood sugar levels closely in individuals receiving opioids like morphine, as opioids can affect glucose metabolism and may necessitate adjustments in insulin dosage.
Correct Answer is C
Explanation
Choice A Reason:
Meloxicam is incorrect. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used primarily for managing mild to moderate pain and inflammation. While it can provide relief for mild pain, it may not be potent enough to effectively manage severe pain, especially in cases of advanced cancer-related pain, where stronger analgesics are often necessary.
Choice B Reason:
Aspirin is incorrect. Aspirin, like meloxicam, is an NSAID used for mild to moderate pain relief and has anti-inflammatory properties. While it can be effective for certain types of pain, it's generally not the first choice for severe pain management, particularly in cases of advanced cancer-related pain where stronger opioids are typically required for adequate relief.
Choice C Reason:
Hydromorphone is correct. Hydromorphone is a potent opioid analgesic used to manage severe pain, especially in cancer-related pain or post-operative settings. In cases of severe pain, opioids like hydromorphone are commonly utilized due to their effectiveness in providing relief.
Choice D Reason:
Caldofor is incorrect. The term "Caldofor" does not appear to correspond to any recognized medication commonly used for pain relief. It's possible that this might be a misspelling or an unfamiliar or less common drug name. Without a specific drug identification, it's challenging to assess its suitability or effectiveness for managing severe pain associated with pancreatic cancer.
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