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?
Bilateral muscle weakness
Thready pulse
Decreased bowel sounds
Distended neck veins
The Correct Answer is D
Choice A Reason:
Bilateral muscle weakness is not typically associated specifically with fluid volume excess. Muscle weakness can result from various causes, such as electrolyte imbalances or certain medical conditions, but it's not a primary manifestation of fluid volume excess.
Choice B Reason:
Thready pulse is not correct. A thready pulse refers to a weak and barely palpable pulse. This is more commonly associated with conditions like shock or reduced cardiac output rather than fluid volume excess.
Choice C Reason:
Decreased bowel sounds is not correct. Reduced or absent bowel sounds may indicate gastrointestinal issues, but they are not a direct manifestation of fluid volume excess. Increased bowel sounds might be more associated with certain types of gastrointestinal disturbances or fluid imbalances, but decreased sounds are not a typical sign of fluid volume excess.
Choice D Reason:
Distended neck veins is correct. In a client experiencing fluid volume excess, distended neck veins can often be observed due to increased venous pressure. This occurs as a result of the body retaining more fluid than it can handle, leading to an increase in blood volume and pressure within the vascular system. This can cause the jugular veins in the neck to appear distended or prominent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Decrease the dose of the medication is incorrect. Lowering the dose could potentially drop the INR below the therapeutic range, increasing the risk of clot formation.
Choice B Reason:
Increase the dose of the medication is incorrect. Raising the dose might push the INR above the therapeutic range, increasing the risk of bleeding.
Choice C Reason:
Withhold the medication is incorrect. Withholding the medication might lead to inadequate anticoagulation and an increased risk of clot formation.
Choice D Reason:
Administer the current dose of the medication. An INR of 2.5 is within the therapeutic range for many indications, including atrial fibrillation. This means the blood is appropriately anticoagulated to prevent clot formation without an excessive risk of bleeding. In this scenario, maintaining the current dose of warfarin is often appropriate to sustain the desired therapeutic effect.
Correct Answer is B
Explanation
Choice A Reason:
"You should report monthly to have your blood drawn to monitor kidney function while taking medication." Is incorrect. While monitoring kidney function might be necessary during tuberculosis treatment due to potential medication side effects, monthly blood draws specifically for kidney function might not be standard. However, periodic blood tests to monitor various parameters, including kidney function, are part of tuberculosis treatment monitoring.
Choice B Reason:
"You will need to take two or more medications to treat your disease." Is correct. Treatment for active pulmonary tuberculosis typically involves a combination of antimicrobial medications to effectively treat the infection and prevent antibiotic resistance. This multidrug therapy is essential to combat the bacteria causing tuberculosis and reduce the risk of treatment failure or relapse.
Choice C Reason:
"You will need to undergo tuberculin skin tests every 6 months while taking medication for your disease." Is incorrect. Tuberculin skin tests are used for screening or diagnosing tuberculosis but are not typically repeated every six months during active treatment for the disease.
Choice D Reason:
"You should anticipate taking medication to treat your disease for at least the next 3 years." Is incorrect. The duration of treatment for active pulmonary tuberculosis varies but is typically shorter than three years. Treatment duration usually lasts several months to a year, depending on the specific medication regimen and the response to treatment.
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