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 C

Explanation

A. Discard the medication if it is yellow: Amphotericin B lipid complex is typically yellow in color. This is a normal characteristic of the medication, and it should not be discarded based on color. The nurse should be aware of the expected color and administer the medication as prescribed.
B. Administer the medication over 2 hr: Amphotericin B lipid complex is often administered over an extended period (usually over 2 to 6 hours) to minimize the risk of infusion-related reactions. However, if the prescription specifies an intermittent IV bolus, the nurse should follow the prescribed administration route and rate.
C. Prime the tubing with 0.9% sodium chloride (Correct Answer): Amphotericin B lipid complex can interact with dextrose-containing solutions, leading to the formation of a precipitate. Therefore, it is recommended to prime the IV tubing with 0.9% sodium chloride before administering the medication to prevent any potential interaction.
D. Use a gravity flow set: The choice of infusion set may depend on the specific institutional policies and the patient's condition. However, using a pump or a controlled infusion device is often recommended when administering medications like amphotericin B to ensure accurate infusion rates and reduce the risk of adverse reactions.

A. A vein that feels hard to the touch B. A vein in the client's dominant arm C. A vein proximal to the previous site D. A vein on the client's wrist

Correct Answer is C

Explanation

A. A vein that feels hard to the touch:
A vein that feels hard to the touch may indicate thrombosis or inflammation and is not a suitable site for catheter insertion.
B. A vein in the client's dominant arm:
The choice of arm may depend on the client's preference, but it is not a strict rule. The nurse can choose a suitable vein in either arm based on factors such as accessibility and vein condition.
C. A vein proximal to the previous site:
This is the correct answer. Placing the catheter proximal (above or upstream) to the previous site helps minimize the risk of complications such as infiltration and thrombophlebitis at the new site. It allows for optimal vein health and reduces the likelihood of complications associated with repeated punctures in the same area.
D. A vein on the client's wrist:
Veins on the wrist may be smaller and more prone to complications. It is generally recommended to choose larger, more accessible veins for catheter insertion.

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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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