A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.

Choice A reason: Taking diuretics with the evening meal increases nighttime urination, worsening urge incontinence by stimulating bladder activity during sleep. Diuretics should be taken earlier (e.g., morning) to align with daytime voiding schedules, reducing urgency episodes. This instruction is counterproductive for bladder retraining, making it inappropriate.
Choice B reason: Planning to urinate every 3 hours while awake establishes a scheduled voiding regimen, a key component of bladder retraining. This helps condition the bladder to delay urgency, reducing involuntary contractions and improving control. It aligns with evidence-based strategies for managing urge incontinence, making it the correct instruction.
Choice C reason: Limiting fluid intake to 1 liter per day risks dehydration and concentrated urine, which can irritate the bladder and worsen urge incontinence. Adequate hydration (2-3 L/day) supports bladder health and retraining by maintaining normal urine volume, making this instruction harmful and incorrect.
Choice D reason: Performing Kegel exercises once daily is insufficient for effective bladder retraining. Multiple daily sets (e.g., 3-4 times) strengthen pelvic floor muscles, improving bladder control. This frequency is too low to achieve therapeutic benefits for urge incontinence, making it less effective than scheduled voiding.