A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Choice A rationale:

"I can plan to eat rice instead of baked potatoes.”. This choice demonstrates an understanding of dietary sources of potassium. Baked potatoes are a good source of potassium, and the client's willingness to substitute rice for baked potatoes indicates that they are aware of alternative potassium-rich foods. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. The client's willingness to make a dietary adjustment is a positive sign.

Choice B rationale:

"Adding pecans will be a change I can readily make.”. While pecans are a good source of potassium, this choice does not directly address the client's ability to substitute a potassium-rich food for one they might need to avoid. It focuses on a new addition to their diet rather than a substitution, making it a less relevant response to the teaching.

Choice C rationale:

"I will eat cantaloupe for my morning snack.”. Cantaloupe is indeed a good source of potassium, but this choice does not indicate an understanding of how to substitute potassium-rich foods in their diet. It only mentions adding cantaloupe as a snack without addressing the potential need for replacing other foods high in potassium. Therefore, it does not fully demonstrate comprehension of the teaching.

Choice D rationale:

"I will miss eating yogurt every day for breakfast.”. This choice expresses a sentiment but does not show an understanding of the teaching regarding dietary sources of potassium. It merely states that the client will miss yogurt without providing any insight into their ability to make appropriate dietary choices to maintain adequate potassium intake.

The correct answer is choice C. Monitor the client for black, tarry stools.

Choice A rationale:

Administering clopidogrel with each meal is not necessary. Clopidogrel can be taken with or without food. The primary concern with clopidogrel is its potential to cause bleeding, so monitoring for signs of bleeding is more critical.

Choice B rationale:

Having suction equipment at the bedside is not specifically required for clients taking clopidogrel. This action is more relevant for clients at risk of airway obstruction or those undergoing procedures that might require suctioning.

Choice C rationale:

Monitoring the client for black, tarry stools is essential because it can indicate gastrointestinal bleeding, a known side effect of clopidogrel. This medication increases the risk of bleeding, so observing for signs of internal bleeding, such as melena (black, tarry stools), is crucial.

Choice D rationale:

Initiating contact precautions is not necessary for clients taking clopidogrel. Contact precautions are typically used to prevent the spread of infections, not for managing clients on antiplatelet therapy.

By understanding these rationales, the nurse can ensure the safe administration and monitoring of clopidogrel therapy.