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)

D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.

A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.

B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.

However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.

C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.

D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.

A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.

B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.

C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.