A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?
Edema
Oliguria
Hypotension
Hyperthemia
The Correct Answer is A
A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.
B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.
C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.
D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Discontinue cardiac monitoring during the infusion:
Discontinuing cardiac monitoring during the infusion of potassium chloride is unsafe. Potassium infusions can significantly impact cardiac function, so continuous cardiac monitoring is necessary to detect any arrhythmias or other complications.
B) Administer KCI as a rapid IV bolus:
Administering potassium chloride as a rapid IV bolus is contraindicated due to the risk of severe adverse effects, including cardiac arrest. Potassium should be infused slowly to avoid complications.
C) Only give the KCI via a central venous line:
Potassium chloride is ideally administered through a central venous line because it is irritating to veins and can cause damage if given through a peripheral line. A central line reduces the risk of irritation and allows for safer infusion of potassium.
D) Infuse the KCI at a rate of 10 mEq/hour:
Infusing potassium chloride at a rate of 10 mEq/hour is generally too slow for an emergency situation requiring immediate correction of severe hypokalemia. For more urgent cases, higher rates may be required, but only under strict medical supervision to avoid complications.
Correct Answer is D
Explanation
A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, maintain the current sodium levels and fluid balance but do not correct hypernatremia. They are not suitable for lowering elevated sodium levels.
B) Total Parenteral Nutrition (TPN): TPN is used for providing comprehensive nutritional support and does not address electrolyte imbalances such as hypernatremia. It is not used to manage sodium levels directly.
C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, increase sodium levels and are used for treating hyponatremia or specific conditions requiring higher sodium concentrations. They would worsen hypernatremia.
D) Hypotonic solution: Hypotonic solutions, like 0.45% sodium chloride (half-normal saline) or Dextrose 5% in water (D5W), are appropriate for treating hypernatremia. They help dilute the sodium concentration in the blood and aid in correcting the elevated sodium levels
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