Electrolytes Question #59
The nurse is caring for a client with fluid volume excess. Which assessment finding will the nurse expect?
- Distension of neck veins
- Flat neck veins
- Increased hemoglobin and hematocrit values
- Decreased central venous pressure readings
The correct answer is A. In fluid volume excess, neck vein distention will occur. Flat neck veins indicate a fluid volume deficit. Increased hemoglobin and hematocrit values indicates hemoconcentration as an indication of fluid volume deficit. A low central venous pressure measurement occurs in fluid volume deficit.
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.