A nurse is observing an older adult client who is receiving packed RBC's. Which of the following findings should the nurse identify as a manifestation of fluid volume excess and report to the charge nurse? (Select all that apply)

Dyspnea

Edema

Bradycardia

Hypertension

Weakness

Answer and Explanation

Correct Answer : A,B,D

A. Dyspnea: Dyspnea, or difficulty breathing, can be a sign of fluid volume excess. Fluid overload can cause pulmonary congestion and lead to respiratory distress. This is a critical manifestation that should be reported.

B. Edema: Edema is a common sign of fluid retention, especially in the lower extremities, and is indicative of fluid volume excess. This should be monitored and reported if observed during the transfusion.

C. Bradycardia: Bradycardia is typically not a sign of fluid volume excess. In fluid volume excess, the heart often tries to compensate for the increased fluid by increasing its rate (tachycardia) to maintain cardiac output, or the rate might remain relatively normal.

D. Hypertension: Hypertension, or high blood pressure, can occur with fluid volume excess as the extra fluid in the circulatory system increases the workload on the heart and raises blood pressure. This is a critical sign of fluid overload that requires reporting.

E. Weakness: Weakness can occur in a variety of conditions, including fluid volume excess, but it is a nonspecific symptom. It is less directly associated with fluid overload compared to the other findings like dyspnea, edema, and hypertension.

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Correct Answer is A

Explanation

A. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg: ACE inhibitors block the conversion of angiotensin I to angiotensin II, which helps relax blood vessels and reduce blood pressure. This is the expected therapeutic effect of ACE inhibitors.

B. Daily weight increase from 55 kg to 57 kg: Increase in daily weight could indicate fluid retention, which is not the intended therapeutic effect of ACE inhibitors. These medications are often prescribed to reduce fluid retention, particularly in conditions like heart failure.

C. Heart rate decrease from 100 beats/min to 82 beats/min: ACE inhibitors primarily affect blood pressure regulation and fluid balance. A decrease in heart rate may occur with other types of medications (e.g., beta-blockers) but is not a primary effect of ACE inhibitors.

D. Respiratory rate increase from 12 breaths/min to 15 breaths/min: ACE inhibitors do not influence respiratory rate. Respiratory rate changes would be more related to respiratory conditions or other medications, not to the pharmacological effects of ACE inhibitors.

A. 0.9% sodium chloride (NS) B. 0.225% sodium chloride (1/4 NS) C. 0.45% sodium chloride (1/2 NS) D. 3% sodium chloride (3% NaCI)

Correct Answer is A

Explanation

A. 0.9% sodium chloride (NS): Normal saline is an isotonic solution that closely matches the osmolality of body fluids. It is the best choice to replace extracellular fluid lost from vomiting and diarrhea.

B. 0.225% sodium chloride (1/4 NS): This hypotonic solution can shift fluids into cells but is not ideal for isotonic therapy. It may cause fluid imbalance and not restore extracellular fluid balance effectively in vomiting and diarrhea.

C. 0.45% sodium chloride (1/2 NS): This is another hypotonic solution that may cause fluid shifts into the cells. It is not isotonic, making it less appropriate for fluid replacement in this case.

D. 3% sodium chloride (3% NaCl): This hypertonic solution is used for severe hyponatremia and shifts fluids out of cells. It is inappropriate for fluid replacement in vomiting and diarrhea, as it could lead to fluid overload.

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A nurse is observing an older adult client who is receiving packed RBC's. Which of the following findings should the nurse identify as a manifestation of fluid volume excess and report to the charge nurse? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme (ACE) inhibitor). For which expected therapeutic effect should the nurse assess?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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