The nurse is assessing an older adult client who is receiving intravenous (IV) therapy. The nurse should recognize that which of the following indicates fluid volume excess. (Select all that apply.)
Distended neck veins
Pitting edema in lower extremities
Crackles in lungs upon auscultation
Swelling at the IV site
Urine specific gravity greater than 1.030
Correct Answer : A,B,C
Choice A reason: Distended neck veins are a classic sign of fluid volume excess. Increased intravascular volume raises venous pressure, which manifests as jugular venous distension. This finding indicates that the circulatory system is overloaded and struggling to handle the excess fluid, often seen in conditions such as heart failure or renal impairment.
Choice B reason: Pitting edema in the lower extremities occurs when excess fluid accumulates in the interstitial spaces due to increased hydrostatic pressure. This is a hallmark of fluid overload, especially in older adults who may have compromised cardiac or renal function. Edema is a reliable indicator of systemic fluid retention.
Choice C reason: Crackles in the lungs upon auscultation are caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This pulmonary congestion is a direct consequence of fluid volume excess and can progress to pulmonary edema if untreated. Crackles are an important clinical sign that the excess fluid is affecting respiratory function.
Choice D reason: Swelling at the IV site is not an indicator of systemic fluid volume excess. Instead, it suggests localized infiltration or phlebitis at the IV insertion site. This is a complication of IV therapy but does not reflect overall fluid overload in the body.
Choice E reason: Urine specific gravity greater than 1.030 indicates concentrated urine, which is typically associated with dehydration rather than fluid volume excess. In fluid overload, urine may be more dilute due to increased renal excretion of water. Therefore, this finding does not support the diagnosis of fluid volume excess.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Repeating the blood pressure in 30 minutes is unsafe because the client’s blood pressure has dropped significantly in a short period. Waiting could delay life-saving interventions. Immediate action is required to address potential shock or cardiovascular collapse.
Choice B reason: Documenting and continuing to monitor is inappropriate because the client is showing signs of acute hypotension. Passive monitoring without intervention places the client at risk for deterioration. Documentation is important but must accompany urgent action.
Choice C reason: Reassuring the client that they are doing well is misleading and unsafe. The client’s blood pressure indicates a critical condition that requires immediate intervention. False reassurance could delay recognition of the seriousness of the situation.
Choice D reason: Calling the Rapid Response team is the most appropriate action. A sudden drop in blood pressure from 120/82 to 88/50 suggests possible shock, internal bleeding, or sepsis. Rapid Response teams are trained to provide immediate advanced interventions, stabilize the client, and prevent cardiac arrest. This action prioritizes patient safety and aligns with emergency protocols.
Correct Answer is B
Explanation
Choice A reason: Background includes relevant medical history, surgical details, and contextual information about the client’s condition. While important, vital signs such as oxygen saturation and heart rate are not categorized under background.
Choice B reason: Assessment is the correct component because it involves the nurse’s clinical evaluation of the client’s current status. Vital signs such as oxygen saturation and heart rate reflect the client’s physiological condition and are part of the assessment data communicated to the provider.
Choice C reason: Recommendation involves the nurse’s suggestion for what should be done next, such as requesting interventions, orders, or changes in treatment. Vital signs are not recommendations but objective data.
Choice D reason: Situation describes the immediate reason for contacting the provider, such as the client’s current problem or concern. While situation sets the context, the actual vital signs are part of the assessment.
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