A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Decreased bowel sounds.

Bilateral muscle weakness.

Thready pulse.

Distended neck veins

Answer and Explanation

The Correct Answer is D

Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.

Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.

Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.

Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.

Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.

Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.

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Correct Answer is D

Explanation

A WBC count of 5,000/mm3 is low and could indicate leukopenia, a possible side effect of amitriptyline. Leukopenia increases the risk of infection and should be reported to the provider.

Choice B is wrong because a total bilirubin of 1.5 mg/dL is within the normal range of 0.3 to 1.9 mg/dL.

Choice C is wrong because a Hct of 44% is within the normal range of 37% to 48% for women and 45% to 52% for men.

Choice D is wrong because a potassium level of 4.2 mEq/L is within the normal range of 3.5 to 5.0 mEq/L.

A. Inject air into the NPH vial. B. Withdraw the NPH insulin from the vial. C. Withdraw the regular insulin from the vial. D. Inject air into the regular insulin vial.

Correct Answer is A

Explanation

The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:

Inject air into the NPH (intermediate-acting) insulin vial: Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.This also helps to equalize the pressure and makes it easier to withdraw the insulin.
Withdraw the regular insulin from the vial: The nurse should withdraw the regular insulin first because it is clear and not contaminated. This prevents any NPH insulin from mixing into the regular insulin vial.
Withdraw the regular insulin from the vial: Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin.

This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.

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A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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