A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

Jugular vein distention

Crackles

Dyspnea

Hypotension

Flat veins

Answer and Explanation

Correct Answer : A,B,C

A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.

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Correct Answer is A

Explanation

A. 50% Dextrose in Water (D50W) IV push is the most appropriate intervention for a client with a blood glucose level of 30 mg/dL, indicating severe hypoglycemia. The rapid administration of D50W will quickly raise the blood glucose level and help restore consciousness.
B. Insulin Regular IV push would lower the blood glucose level, which is not appropriate in this situation where the client is hypoglycemic.
C. 0.9% sodium chloride infusion is a general fluid replacement solution, but it will not address the client's low blood glucose level.
D. 5% Dextrose continuous IV infusion is typically used for maintenance, but it would not act as quickly as D50W to correct severe hypoglycemia in an unconscious patient.

A. The pain comes from severed blood vessels in the residual stump. B. It is psychosomatic pain that the patient is just imagining. C. It is often treated with adjunct medications such as antiepileptics and antidepressants. D. It is somatic pain that always responds well to opioid medications.

Correct Answer is C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

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A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

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Correct Answer is A

Explanation

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