A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

Increased thirst and dry mucous membranes

Low blood pressure and increased heart rate

Difficulty breathing and weight gain

Dry cough and poor skin turgor

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.

Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.

Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.

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Correct Answer is C

Explanation

Choice A reason: Securing the drain to the client's bed sheet is not the best action for the nurse to take. This could cause the drain to be pulled or dislodged if the client moves or changes position. The nurse should secure the drain to the client's gown or abdominal binder, using a safety pin or a clip.

Choice B reason: Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze, is not the correct action for the nurse to take. The nurse should not remove the drain without a physician's order, as this could cause complications such as infection, bleeding, or bile leakage. The nurse should monitor the amount and color of the drainage, and report any changes to the physician.

Choice C reason: Expelling the air from the JP bulb after emptying to re-establish suction is the correct action for the nurse to take. The JP drain works by creating a negative pressure that draws fluid from the surgical site. The nurse should empty the bulb when it is half full, and squeeze it until it collapses before closing the plug. This ensures that the suction is maintained and prevents the fluid from flowing back into the drain.

Choice D reason: Measuring the drainage every hour for the first 8 hr postoperative is not the correct action for the nurse to take. This is too frequent and unnecessary, as the drainage is expected to decrease over time. The nurse should measure the drainage every 8 to 12 hr, or as ordered by the physician, and record the volume and color. The nurse should also report any signs of infection, such as fever, pain, or foul odor.

A. Active transport B. Diffusion C. Filtration D. Osmosis

Correct Answer is B

Explanation

Choice A reason: Active transport is the process of moving molecules across a cell membrane against a concentration gradient, requiring energy.

Choice B reason: Diffusion is the process of moving molecules from an area of high concentration to an area of low concentration, without using energy.

Choice C reason: Filtration is the process of moving fluid and solutes through a membrane by a pressure gradient.

Choice D reason: Osmosis is the process of moving water across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration.

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A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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