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A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

A.

Oliguria

B.

Bradycardia

C.

Dyspnea

D.

Poor skin turgor

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A. Low-sodium diet Contraindicated: A low-sodium diet can decrease lithium elimination, leading to increased lithium levels and risk of toxicity in lithium users. B. Potassium 40 mEq PO daily Anticipated: Potassium supplementation may be needed to prevent hypokalemia, which can occur due to lithium-induced polyuria or diuretic use. C. Initiate suicide precautions Anticipated: Suicide precautions are essential for any client who has attempted or expressed suicidal ideation, especially during the depressive phase of bipolar disorder. D. Fluoxetine 20 mg PO daily Contraindicated: Fluoxetine is an SSRI antidepressant, which can cause angioedema in clients who are allergic to SSRIs. Additionally, fluoxetine can trigger manic episodes or increase suicidal risk in clients with bipolar disorder.

Correct Answer is D

Explanation

A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.

B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.

C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.

D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.

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