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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "If I were you, I would get the vaccine to keep my family safe:"
This statement imposes the nurse's personal opinion on the client and may not respect the client's autonomy and decision-making.
B. "Influenza can be very serious to anyone who does not receive the vaccine:"
While this statement conveys the seriousness of influenza, it may be perceived as coercive or fear-inducing. It is important to provide information without pressure.
C. "The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form:"
This statement is not accurate and may create unnecessary tension. Influenza vaccination is generally not mandatory, and clients have the right to decline without being labeled against medical advice for this particular vaccination.
D. "The influenza vaccine is strongly encouraged, but I understand you would like to decline right now:"
This is the correct answer. It acknowledges the client's decision to decline the vaccine while expressing that the vaccine is encouraged. It respects the client's autonomy and allows for open communication about the decision.

A. PT 11 seconds B. APTT 50 seconds C. Hematocrit 456 D. Platelets 300,000/mm²

Correct Answer is C

Explanation

A.PT (Prothrombin Time) 11 seconds: The prothrombin time measures the extrinsic pathway of the coagulation cascade. A PT of 11 seconds is within the normal range, and it indicates that the extrinsic clotting pathway is functioning appropriately. There is no need to report this value.
B. APTT (Activated Partial Thromboplastin Time) 50 seconds: The APTT measures the intrinsic pathway of the coagulation cascade. A value of 50 seconds is prolonged and may suggest that the client is receiving an effective anticoagulant dose. However, the APTT target range can vary based on the specific therapeutic goal and the heparin protocol in use. It's essential to follow the healthcare provider's guidance on the target APTT range.
C. Hematocrit 456: The normal range for hematocrit is usually expressed as a percentage. A value of 456 is outside the normal range and likely represents an error or a misinterpretation. The nurse should verify this value, as an extremely high hematocrit could be indicative of an issue such as dehydration or an analytical error.
D. Platelets 300,000/mm²: A platelet count of 300,000/mm² is within the normal range. There is no need to report this value as it suggests a normal platelet count.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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