Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Neck veins are now distended in the sitting position.

Breath sounds can be heard in the right lower lung lobe.

Weight is unchanged from that obtained yesterday.

Nose and ears have a slightly yellow-tinged appearance.

Answer and Explanation

The Correct Answer is A

Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.

Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.

Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.

Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.

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Correct Answer is A

Explanation

Choice A reason: Octreotide reduces portal hypertension and bleeding in esophageal varices by constricting splanchnic blood flow. This aligns with acute variceal bleed management, making it the correct medication the nurse would expect to be administered to the actively bleeding client.

Choice B reason: Propranolol prevents variceal bleeding long-term but is not used for active bleeding. Octreotide is acute treatment, making this incorrect, as it’s inappropriate for the nurse’s expectation in managing the client’s immediate esophageal variceal hemorrhage.

Choice C reason: Lactulose treats hepatic encephalopathy, not active variceal bleeding. Octreotide controls acute hemorrhage, making this incorrect, as it’s unrelated to the nurse’s priority of administering a medication to stop the client’s esophageal variceal bleeding in the emergency.

Choice D reason: Spironolactone manages ascites in liver disease, not acute variceal bleeding. Octreotide is the treatment for active bleeding, making this incorrect, as it’s irrelevant to the nurse’s expectation for a medication to control the client’s esophageal variceal hemorrhage.

A. Assisting the patient with ambulation and evaluating pain level. B. Administering prescribed medication and monitoring for side effects. C. Performing a full head-to-toe assessment and identifying any complications. D. Educating the patient on discharge instructions for post-operative care.

Correct Answer is B

Explanation

Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.

Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.

Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.

Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.

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Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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