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 D
Explanation
Choice A Reason:
Discard the medication if it is yellow is incorrect. While amphotericin B lipid complex can have a yellowish color, it's important to follow specific guidelines provided by the manufacturer or pharmacy regarding any discoloration or changes in the medication's appearance. Discoloration could indicate degradation or contamination, and it's crucial to adhere to specific institutional policies in such cases.
Choice B Reason:
Administer the medication over 2 hr is incorrect. Amphotericin B lipid complex is usually given over a longer duration (e.g., several hours) due to the potential for infusion-related reactions. Intermittent IV bolus administration over 2 hours might not be appropriate and can increase the risk of adverse reactions.
Choice C Reason:
Use a gravity flow set is incorrect. For medications like amphotericin B lipid complex, which often require precise infusion rates and careful monitoring, using an IV infusion pump is usually recommended instead of a gravity flow set. An infusion pump allows for more accurate control of the infusion rate and reduces the risk of errors.
Choice D Reason:
Prime the tubing with 0.9% sodium chloride is correct. Amphotericin B lipid complex should be administered according to specific instructions and precautions. Priming the IV tubing with 0.9% sodium chloride helps ensure that the medication is effectively delivered to the patient and that the medication is not affected by remnants of previous IV solutions in the tubing.
Correct Answer is D
Explanation
Choice A Reason:
"I will check the client's INR before administering the heparin." is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps reduce the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in minimizing bleeding at the injection site.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.