A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)
"I think my ankles look less swollen today."
"I felt a little dizzy when I got out of bed this morning."
"I feel as if my heart is beating very fast.
"I am a little short of breath today."
The CNA told me that my blood pressure was 150 over 98 this morning."
Correct Answer : C,D,E
C. Rapid heart rate (tachycardia) can be a sign of fluid overload, as the heart compensates for increased volume by beating faster to maintain cardiac output.
D. Shortness of breath (dyspnea) can indicate fluid overload, especially if it is new or worsening and associated with pulmonary congestion due to fluid accumulation.
E Elevated blood pressure can be a sign of fluid overload, as increased circulating volume can lead to hypertension.
A. This statement suggests a decrease in peripheral edema, which is a positive sign and does not typically indicate fluid overload. It may actually indicate improvement.
B. Dizziness can be a symptom of hypovolemia (low fluid volume) rather than fluid overload. It is not typically a specific sign of fluid overload.
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Related Questions
Correct Answer is B
Explanation
B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.
A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.
C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.
D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.
Correct Answer is D
Explanation
D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.
A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.
B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.
C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.
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