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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: While legs feeling heavy can be a common sensation after a spinal block, it is not as concerning as other potential symptoms.
Choice B reason: Hypotension is a significant concern following a spinal block as it can indicate a high level of blockage affecting the autonomic nerves, which can lead to serious complications.
Choice C reason: Numbness below the injection site is expected after a spinal block and is not typically a cause for concern unless it is prolonged or accompanied by other symptoms.
Choice D reason: Nausea can occur but is less concerning than hypotension, which can have more immediate and severe consequences.
Correct Answer is A
Explanation
Choice A reason: Clients with OCD often engage in compulsive behaviors, such as cleaning, to manage their anxiety levels. Recognizing this can help the nurse provide appropriate support and interventions.
Choice B reason: While the tasks may seem useful, the compulsive nature of the behavior is driven by anxiety rather than a focus on productivity.
Choice C reason: The behavior is not about limiting social interaction; it is a manifestation of the client's OCD.
Choice D reason: The behavior is not intended to manipulate or control others but is a symptom of the client's OCD.
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