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 ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

A. Allow the client to take her morning vitamins. B. Allow the client to keep her tongue stud in. C. Allow the client to consume clear liquids up to the time of surgery. D. Allow the client to keep her hearing aids in.

Correct Answer is D

Explanation

Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.

Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.

Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.

Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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