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. Intracellular: The majority of the body's total water volume is contained within the intracellular compartment, which makes up about 2/3 total body water. Intracellular fluid is essential for cellular function, and any depletion here contributes significantly to dehydration.

B. Extracellular: While extracellular fluid (ECF) accounts for about one-third of total body water, it is not the compartment that holds the majority. ECF includes interstitial fluid, blood plasma, and lymph, but intracellular fluid still holds a larger proportion.

C. Intravascular: Intravascular fluid is a subset of extracellular fluid, specifically the fluid found within blood vessels. It makes up a smaller portion of total body water and is primarily involved in transporting nutrients and waste.

D. Transcellular: Transcellular fluid is a small compartment of extracellular fluid, including fluids such as cerebrospinal fluid, synovial fluid, and ocular fluid. It represents a very small fraction of total body water.

A. Excessive thirst B. Irregular heartbeat C. Swelling of ankles D. Frightening hallucinations

Correct Answer is B

Explanation

A. Excessive thirst: Excessive thirst, polydipsia, is not the most immediate concern with a potassium level of 5.2 mEq/L. Potassium levels within this range (slightly elevated) may not directly cause excessive thirst.

B. Irregular heartbeat: Elevated potassium levels can cause dangerous cardiac arrhythmias, including irregular heartbeat. Therefore, the most important assessment is monitoring for signs of cardiac disturbances.

C. Swelling of ankles: Swelling of the ankles is more commonly associated with fluid retention or circulatory issues and is not directly linked to minor elevations in potassium levels. Although elevated potassium can affect fluid balance, it does not immediately present as swelling.

D. Frightening hallucinations: Hallucinations can be caused by a variety of factors, but they are not a direct effect of slightly elevated potassium levels. More serious symptoms like cardiac arrhythmias are a more immediate concern with abnormal potassium levels.

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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 patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in which compartment?

Correct Answer is A

Explanation

The K laboratory report shows a level of 5.2 mEq/L (Normal 3.5-5.0 mEq/L). What is the most important assessment for the nurse to make?

Correct Answer is B

Explanation

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