Electrolytes Question #12

Question

The nurse notes that a client with heart failure has dyspnea and audible crackles upon auscultation. Which additional sign should the nurse expect if this client is experiencing excess fluid volume?

Answers

  1. Weight loss
    • Rationale:
  2. Flat neck and hand veins
    • Rationale:
  3. An increase in blood pressure
    • Rationale:
  4. A decreased central venous pressure (CVP)
    • Rationale:

Overview

Explanation

The correct answer is C. Manifestations of excess fluid volume include a cough, crackles, dyspnea, an elevated blood pressure, bounding pulses, an elevated CVP, weight gain, altered level of consciousness, a decreased hematocrit, neck and hand vein distention, tachycardia, and tachypnea. Weight loss, a decreased CVP, and flat hand and neck veins would indicate deficient fluid volume.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale