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 B, D, C, A

Explanation

A. Inject air into the NPH insulin vial: Start by injecting air into the NPH insulin vial. This step prevents creating a vacuum in the vial, making it easier to withdraw the correct dose of insulin.

B. Inject air into the regular insulin vial: After injecting air into the NPH insulin vial, inject air into the regular insulin vial. This step equalizes the pressure within the vial and makes it easier to withdraw the insulin.

C. Withdraw the regular insulin from the vial: Once the air has been injected into the regular insulin vial, withdraw the required dose of regular insulin from the vial.

D. Withdraw the NPH insulin from the vial: After withdrawing the regular insulin, withdraw the required dose of NPH insulin from its vial.

A. Infiltration B. Extravasation C. Venous spasm D. Phlebitis

Correct Answer is D

Explanation

A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.

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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

A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Correct Answer is B, D, C, A

Explanation

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Correct Answer is D

Explanation

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