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."

Answer and Explanation

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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Correct Answer is A

Explanation

A. Gender can influence health beliefs and practices due to societal norms, roles, and expectations associated with masculinity and femininity. For example, certain health issues may be more prevalent or

stigmatized based on gender. Understanding a client's gender-related health beliefs can help nurses tailor care that respects and addresses these factors.

B. Socioeconomic status (SES) impacts access to healthcare resources, health literacy, and health behaviors. Clients with higher SES may have greater access to healthcare facilities, medications, and preventive services. However, this is an external variable.

C. Family health practices often shape an individual's beliefs about health and illness. Clients may adopt health behaviors based on familial traditions, cultural practices, or experiences with illness within the family. However, this is an external variable.

D. Education level influences health literacy, understanding of medical information, and decision-making regarding healthcare. Higher education levels are often associated with better health outcomes due to increased knowledge of health-related issues, ability to navigate healthcare systems, and adherence to medical advice. However, this is an external variable.

A. Change bed linens on a daily basis. B. Provide fresh drinking water every four hours. C. Restrict visitors who have an upper respiratory infection. D. Monitor intake and output every shift.

Correct Answer is C

Explanation

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

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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)

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Naxlex Comprehensive Predictor Exams

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

Correct Answer is A

Explanation

The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Correct Answer is C

Explanation

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