A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Choice A reason: Decreased blood pressure is not a direct sign of fluid overload; it may indicate hypovolemia or shock. Fluid overload increases intravascular volume, typically raising pressure initially. This finding contradicts the excess fluid state in enteral feeding complications, where the body retains too much water, affecting other systems first.

Choice B reason: Decreased skin turgor suggests dehydration, not fluid overload. In overload, excess fluid accumulates in tissues, potentially causing edema, not poor elasticity. Enteral feeding can lead to overhydration if mismanaged, making turgor an unreliable indicator here, as it reflects fluid deficit rather than the excess seen in this scenario.

Choice C reason: Weight loss occurs with fluid loss or malnutrition, not overload. Fluid overload from enteral feedings causes rapid weight gain due to water retention. This finding opposes the expected physiology of excess fluid, where the body holds onto water, increasing mass, not shedding it as in dehydration.

Choice D reason: Crackles in the lungs indicate fluid overload, as excess fluid from enteral feedings backs up into pulmonary circulation, causing pulmonary edema. This audible sign reflects fluid escaping into alveoli, impairing gas exchange, a common complication when intake exceeds the body’s ability to excrete water effectively.

Choice A reason: Using a trapeze builds upper body strength, aiding transfers and mobility post-amputation. Scientifically, this promotes independence by enhancing muscle power for prosthetic use, aligning with rehabilitation goals to restore function and reduce reliance on others early in recovery.

Choice B reason: Abduction with a pillow prevents adduction contractures but doesn’t directly enhance mobility. It’s passive, not active, support. Scientifically, while useful, it lacks the progressive impact of strength training, making it secondary to fostering independence in amputation care.

Choice C reason: Avoiding prone position is outdated; prone lying prevents hip flexion contractures, aiding mobility. Scientifically, this caution hinders rehabilitation, as stretching the hip flexors supports prosthetic alignment and walking, contradicting progression toward independence.

Choice D reason: Loose dressings don’t promote mobility; tight, controlled dressings reduce edema for prosthetic fitting. Scientifically, this delays healing and strength-building, as proper wound management, not loose coverage, supports physical progression in amputation recovery.