A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Oliguria
Bradycardia
Dyspnea
Poor skin turgor
The Correct Answer is C
A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.
B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.
C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.
D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and self-inflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.
B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.
C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.
D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.
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