A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

A) Increase hematocrit: Fluid overload typically results in dilutional effects on the blood, leading to a decrease in hematocrit rather than an increase. Hematocrit levels may decrease due to the relative decrease in the concentration of red blood cells in relation to plasma.

B) Increased temperature: Fluid overload is not typically associated with an increase in body temperature. While fever can occur as a result of infection, it is not a direct manifestation of fluid overload.

C) Increased heart rate: Fluid overload can lead to increased blood volume, which results in an increased workload for the heart. As a compensatory mechanism, the heart rate may increase to maintain adequate cardiac output.

D) Increased respiratory rate: Fluid overload can cause pulmonary congestion and impair gas exchange in the lungs, leading to respiratory distress. As a result, the respiratory rate may increase as the body attempts to compensate for the decreased oxygenation.

E) Increased blood pressure: Fluid overload can lead to an increase in blood volume, which results in increased pressure within the blood vessels. As a result, blood pressure may rise as the heart works harder to pump the excess fluid throughout the body.

Answer: B. The padding of the restraints is against the client's bony prominences.

A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.

B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.

C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.

D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.