Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is taking an osmotic laxative.
Which of the following findings should the nurse identify as an indication of fluid volume deficit?
A. Oliguria.
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
B. Nausea.
Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
C. Headaches.
Headaches are wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment. Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
D. Weight gain.
Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
One of the signs of fluid volume deficit is oliguria, which means low urine output.
Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.
Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
Similar Questions
A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?
A. Increased pulse rate.
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
B. Increased blood pressure.
Hypotension, not hypertension, is a sign of significant blood loss.
C. Decreased temperature.
While severe shock can lead to hypothermia, temperature changes are not an early indicator of heparin overdose.
D. Decreased respiratory rate.
If bleeding leads to hypovolemic shock, respiratory rate would likely increase, not decrease.
Full Explanation
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?
A. Decreased bowel sounds.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess. Decreased bowel sounds can indicate ileus, obstruction, or peritonitis.
B. Bilateral muscle weakness.
Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess. Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
C. Thready pulse.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess. Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
D. Distended neck veins
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Full Explanation
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
A. Pallor.
Choice A is wrong because pallor is not a typical sign of an allergic reaction to penicillin. Pallor means pale skin and may be caused by other conditions such as anemia or shock.
B. Bradycardia.
Choice B is wrong because bradycardia is not a typical sign of an allergic reaction to penicillin. Bradycardia means slow heart rate and may be caused by other conditions such as heart block or medication side effects.
C. Urticaria.
Urticaria, also known as hives, is a common sign of an allergic reaction to penicillin. An allergic reaction is an abnormal response of the immune system to the drug. Other signs and symptoms of penicillin allergy may include skin rash, itching, fever, swelling, shortness of breath, wheezing, runny nose, itchy eyes, and anaphylaxis. Anaphylaxis is a rare but life-threatening condition that affects multiple body systems and requires immediate emergency treatment.
D. Dyspepsia.
Choice D is wrong because dyspepsia is not a typical sign of an allergic reaction to penicillin. Dyspepsia means indigestion and may be caused by other conditions such as gastritis or peptic ulcer.
Full Explanation
Urticaria, also known as hives, is a common sign of an allergic reaction to penicillin. An allergic reaction is an abnormal response of the immune system to the drug. Other signs and symptoms of penicillin allergy may include skin rash, itching, fever, swelling, shortness of breath, wheezing, runny nose, itchy eyes, and anaphylaxis. Anaphylaxis is a rare but life-threatening condition that affects multiple body systems and requires immediate emergency treatment.
Choice A is wrong because pallor is not a typical sign of an allergic reaction to penicillin.
Pallor means pale skin and may be caused by other conditions such as anemia or shock.
Choice B is wrong because bradycardia is not a typical sign of an allergic reaction to penicillin.
Bradycardia means slow heart rate and may be caused by other conditions such as heart block or medication side effects.
Choice D is wrong because dyspepsia is not a typical sign of an allergic reaction to penicillin.
Dyspepsia means indigestion and may be caused by other conditions such as gastritis or peptic ulcer.