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 C

Explanation

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

A. Have the son verify that the patient understands the risks and benefits of the procedure by repeating them back to him. B. Explain to the provider, patient, and family that you will contact the hospital translator before continuing. C. Offer to help clarify any questions the client may have, using the son to translate. D. Ensure that both the provider, client, and son have all signed the consent form.

Correct Answer is B

Explanation

A. While having the son verify understanding may seem appropriate, using a family member as a translator is not acceptable for informed consent due to the potential for miscommunication or bias.
B. Contacting the hospital translator ensures accurate and professional communication. A certified translator is required for legal and ethical reasons to ensure the patient fully understands the procedure, risks, and benefits.
C. Using the son to clarify questions may lead to inaccuracies or incomplete understanding. Professional translation services must be utilized in medical settings.
D. The son does not need to sign the consent form. The provider must ensure the patient understands the procedure, and the consent form is signed by the patient or their legal representative after professional translation.

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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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Naxlex Comprehensive Predictor Exams

Which assessment finding is most indicative of hypernatremia?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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