NURS 601: Quiz 2 Questions with Complete Solutions

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP) Correct Answer-Correct answer: 3 Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output {is noted in fluid volume excess}, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. NOTE: In fluid volume excess, the intake usually exceeds the output and thus urine output decreases. What makes option 2 incorrect is the flat neck veins. In fluid volume excess, neck veins will be distended. Cognitive Ability: Synthesizing