A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Bounding pulse.

Elevated temperature.

Warmth at IV site.

Profuse sweating.

Crackles in lungs.

Answer and Explanation

Correct Answer : A,E

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

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Correct Answer is A

Explanation

Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.

Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.

Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.

Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.

A. "A heating pad will be used on the operative site to help reduce pain." B. "Expect to remain in bed for at least the first 24 hours." C. "You will use a continuous passive motion (CPM) machine several times a day." D. "You will use a special soap to shower with the evening before your surgery."

Correct Answer is C

Explanation

Choice A reason: The use of a heating pad on the operative site is not typically recommended immediately post-surgery due to the risk of bleeding and swelling.

Choice B reason: Patients are encouraged to mobilize as soon as possible after surgery to prevent complications such as deep vein thrombosis and pulmonary embolism.

Choice C reason: The use of a CPM machine is common after total hip replacement surgery to help restore joint function and prevent stiffness.

Choice D reason: Using a special soap the evening before surgery is part of the preoperative preparation to reduce the risk of infection.

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A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is reinforcing preoperative teaching to a client who is undergoing total hip replacement surgery. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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