A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

Pyuria

Weight loss

Jugular vein distention

Muscle contractions

Answer and Explanation

The Correct Answer is C

Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.

Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.

Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.

Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Guarding and rebound tenderness are signs of peritonitis, which is a serious complication of colonoscopy. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can be caused by perforation or puncture of the colon during the colonoscopy, which allows bacteria and fecal matter to enter the peritoneal space. The nurse should monitor the client for signs of peritonitis, such as abdominal pain, rigidity, fever, and leukocytosis.

Choice B reason: Nausea and vomiting are not specific signs of a complication of colonoscopy. They may be caused by other factors, such as the sedation, the bowel preparation, or the ingestion of food or fluids after the procedure. Nausea and vomiting may also be symptoms of other conditions, such as gastroenteritis, food poisoning, or pregnancy.

Choice C reason: Diarrhea is not a sign of a complication of colonoscopy. Diarrhea may be a normal consequence of the bowel preparation, which involves taking laxatives or enemas to clear the colon before the procedure. Diarrhea may also be caused by other factors, such as the ingestion of food or fluids after the procedure, or the presence of an underlying bowel disorder, such as irritable bowel syndrome or inflammatory bowel disease.

Choice D reason: Hyperactive bowel sounds are not a sign of a complication of colonoscopy. Hyperactive bowel sounds may indicate increased peristalsis, which is the movement of the digestive tract. Hyperactive bowel sounds may be a normal response to the bowel preparation, the ingestion of food or fluids after the procedure, or the stimulation of the colon during the colonoscopy. Hyperactive bowel sounds may also be present in conditions such as diarrhea, gastroenteritis, or intestinal obstruction.

A. H2-receptor antagonist and two antibiotics B. Two proton-pump inhibitors and an antibiotic C. H2-receptor antagonist, proton pump inhibitor, and an antibiotic D. Proton-pump inhibitor and two antibiotics

Correct Answer is D

Explanation

Choice A reason: H2-receptor antagonist and two antibiotics is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists are drugs that block the action of histamine on the stomach cells, reducing the production of acid. They are used to treat peptic ulcers, but they are not effective against H. pylori bacteria. The "triple therapy" regimen requires an antibiotic to kill the bacteria, and a proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice B reason: Two proton-pump inhibitors and an antibiotic is not the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, but they are not enough to eradicate H. pylori bacteria. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice C reason: H2-receptor antagonist, proton pump inhibitor, and an antibiotic is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists and proton-pump inhibitors have similar effects on the stomach acid, but they work in different ways. They are both used to treat peptic ulcers, but they are not necessary to use together. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.

Choice D reason: Proton-pump inhibitor and two antibiotics is the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, and they also enhance the effectiveness of the antibiotics. The "triple therapy" regimen requires two antibiotics to kill the H. pylori bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing. The most common antibiotics used are amoxicillin, clarithromycin, and metronidazole.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client with suspected fluid volume overload. Which finding requires further action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diverticular disease has just returned from a colonoscopy. While conducting an abdominal assessment, the nurse monitors for which of the following as an initial sign of a possible complication of the procedure?

Correct Answer is A

Explanation

The nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on?

Correct Answer is D

Explanation

Fluid and electrolyte balance is maintained through the process of fluid and solutes moving in and out of cells. What specific process allows fluid to pass through a membrane from a dilute to a more concentrated area?

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo which preferred treatment?

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

A client with obesity is prescribed orlistat for weight loss. The client asks the nurse, "I understand the medication prevents digestion of fat, but what side effects does this cause?" Which of the following responses by the nurse are correct? SELECT ALL THAT APPLY

A postoperative bariatric surgery client is complaining of nausea. Which intervention should the nurse facilitate?