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?
Thready pulse
Decreased bowel sounds
Bilateral muscle weakness
Distended neck veins
The Correct Answer is D
A. Thready pulse:
A thready pulse is more indicative of fluid volume deficit or inadequate cardiac output, not fluid volume excess.
B. Decreased bowel sounds:
Decreased bowel sounds are not a specific sign of fluid volume excess. They may be associated with various gastrointestinal issues but are not directly related to fluid volume status.
C. Bilateral muscle weakness:
Bilateral muscle weakness is not a specific manifestation of fluid volume excess. It may be associated with electrolyte imbalances or other neuromuscular issues.
D. Distended neck veins:
This is the correct answer. Distended neck veins are a classic sign of fluid volume excess or overload. Increased venous pressure from excess fluid can lead to distension of the jugular veins in the neck. This finding is often seen in conditions such as heart failure or renal failure where there is an inability to adequately excrete or distribute fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dark amber urine:
Dark amber urine is not typically an adverse effect of receiving 0.9% sodium chloride solution. It may be a sign of concentrated urine, dehydration, or the presence of certain substances, but it is not a direct adverse effect of the solution itself.
B. Decreased skin turgor:
Decreased skin turgor is a clinical manifestation of dehydration and is not an adverse effect of 0.9% sodium chloride solution. The solution is administered to address dehydration and restore fluid balance.
C. Increased bowel sounds:
Increased bowel sounds are not an adverse effect of 0.9% sodium chloride solution. Bowel sounds are influenced by various factors, including the presence of gas and peristalsis, but they are not directly related to the administration of this isotonic solution.
D. Pink, frothy sputum:
This is the correct answer. Pink, frothy sputum is a potential sign of pulmonary edema, which can be associated with fluid overload. Administering 0.9% sodium chloride solution too rapidly or in excessive amounts can lead to fluid overload and pulmonary edema.
Correct Answer is A
Explanation
A. Decrease in urine output:
This is the correct answer. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that works to reduce urine output in individuals with diabetes insipidus. A decrease in urine output indicates a positive response to the medication.
B. Increase in serum glucose:
Desmopressin does not have a direct effect on serum glucose levels. Its primary action is to increase water reabsorption in the kidneys, reducing urine output.
C. Increase in WBC count:
Desmopressin does not have a direct impact on white blood cell (WBC) count. Its main action is on fluid balance and urine concentration.
D. Decrease in blood pressure:
Desmopressin can cause a mild increase in blood pressure, particularly at higher doses. However, blood pressure changes are not the primary therapeutic effect of desmopressin in the context of diabetes insipidus.
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