A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Hypotension

Weak, thready pulse

Slow capillary refill

Distended neck veins

Answer and Explanation

The Correct Answer is D

A. Hypotension: Hypotension is more commonly associated with fluid volume deficit rather than fluid overload. When intravascular volume is low, cardiac output decreases, resulting in reduced blood pressure. In fluid volume excess, the circulating blood volume increases, which typically leads to elevated blood pressure due to increased preload and vascular pressure.

B. Weak, thready pulse: A weak, thready pulse usually occurs in hypovolemia, where there is insufficient circulating blood volume to maintain adequate perfusion. In fluid volume excess, the pulse is more likely to be bounding due to increased stroke volume and elevated intravascular pressure, reflecting increased cardiac workload.

C. Slow capillary refill: Delayed capillary refill indicates poor peripheral perfusion, often seen in dehydration, shock, or fluid volume deficit. In fluid volume excess, circulation is generally adequate or increased, and capillary refill is not typically delayed unless severe cardiac dysfunction or circulatory compromise develops.

D. Distended neck veins: Jugular venous distention (JVD) occurs when increased intravascular volume causes elevated central venous pressure. This leads to visible engorgement of the neck veins. JVD is a classic clinical sign of fluid overload and may also be accompanied by edema, hypertension, and pulmonary congestion.

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Free Nursing Study Resources

Correct Answer is ["A","B","G"]

Explanation

A. Teach the client to shift their weight every hour when sitting: After knee replacement surgery, prolonged pressure on the same area can impair circulation and increase the risk of pressure injuries. Teaching the client to shift weight regularly promotes blood flow, reduces prolonged pressure on tissues, and supports skin integrity.

B. Assist the client to dangle their legs at the bedside prior to standing: Dangling the legs before standing helps the body gradually adjust to positional changes and reduces the risk of orthostatic hypotension. The client’s blood pressure decreased to 92/64 mm Hg at 0930, suggesting possible postural instability. Allowing time for cardiovascular adjustment promotes safety and reduces the risk of dizziness or falls during early ambulation.

C. Massage the client's lower legs to promote circulation: Massaging the lower legs is contraindicated for postoperative clients, especially those at risk for deep vein thrombosis. Manipulating the calf muscles could potentially dislodge a thrombus and lead to a pulmonary embolism. Circulation should be promoted through ambulation, compression devices, and leg exercises.

D. Perform passive range of motion exercises once a day: Passive range of motion exercises are typically indicated for clients who are unable to move their extremities independently. A postoperative knee replacement client who is alert and preparing for physical therapy should participate in active or assisted range of motion exercises as directed by the therapy team. Performing passive exercises only once daily would not adequately support rehabilitation.

E. Delegate the application of sequential compression devices to assistive personnel: Applying sequential compression devices requires assessment of skin integrity, proper placement, and evaluation of circulation. These responsibilities require nursing judgment, particularly in a postoperative client who is at risk for circulatory complications.

F. Encourage the client to bear down when moving up in bed: Bearing down involves performing a Valsalva maneuver, which can increase intrathoracic pressure and reduce venous return to the heart. This can lead to sudden drops in blood pressure and potential cardiovascular strain. Postoperative clients should be instructed to exhale during exertion rather than holding their breath.

G. Administer analgesic prior to planned activities: Providing pain medication before physical therapy or mobility activities helps control procedural and movement-related pain. Effective analgesia improves the client’s ability to participate in rehabilitation exercises and ambulation, which are critical for recovery after knee replacement surgery.

A. Bend at the waist. B. Stand close to the cabinet when lifting it. C. Use the back muscles for lifting. D. Keep the feet close together.

Correct Answer is B

Explanation

A. Bend at the waist: Bending at the waist while lifting places excessive strain on the lumbar spine and increases the risk of back injury. Proper lifting technique requires bending at the knees and hips while keeping the back straight to distribute the weight more safely across the larger leg muscles.

B. Stand close to the cabinet when lifting it: Standing close to the object reduces leverage and minimizes the force on the lower back. Keeping the load near the body maintains balance, improves control, and decreases the risk of musculoskeletal injury, making this a key ergonomic principle for safe lifting.

C. Use the back muscles for lifting: Lifting primarily with the back muscles increases the risk of strain or injury to the lumbar region. Instead, the nurse should engage the strong muscles of the legs and gluteal region to perform the lift safely while keeping the back aligned.

D. Keep the feet close together: Keeping the feet close together reduces stability and balance while lifting. A proper stance requires feet shoulder-width apart to provide a broad base of support, allowing safe weight transfer and reducing the risk of falls or musculoskeletal injury.

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A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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