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 C

Explanation

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

A. Drugs with a short half-life have a greater risk for toxicity B. Half-life is not affected by renal or hepatic function C. if a medication has a long half-life. dosage times can be longer intervals & the drug remains effective D. Half of the effective portion of the drug is metabolized by the liver

Correct Answer is C

Explanation

C. The half-life of a drug refers to the time it takes for the concentration of the drug in the bloodstream to be reduced by half. If a medication has a long half-life, it means that it stays in the body for a longer period before being eliminated. This allows for less frequent dosing intervals while still maintaining therapeutic effectiveness.

A. Drugs with a short half-life are typically cleared from the body more quickly. While they may require more frequent dosing to maintain therapeutic levels, they do not necessarily have a greater risk for toxicity compared to drugs with longer half-lives. In fact, drugs with longer half-lives can accumulate in the body over time, potentially increasing the risk of toxicity.

B. The half-life of a drug can be significantly influenced by renal (kidney) and hepatic (liver) function. Impaired renal or hepatic function can prolong the half-life of a drug, leading to slower elimination and potentially increased risk of adverse effects.

D. This statement describes the concept of drug metabolism rather than the half-life. Drug metabolism refers to the biochemical alteration of drugs by enzymes, often occurring in the liver. The half-life, on the other hand, specifically relates to the elimination of the drug from the body.

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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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Correct Answer is C

Explanation

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