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 C

Explanation

Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.

Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.

Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.

Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.

A. "We are here to help you and give you the care that you need right now." B. "Do you feel that you don't belong here?" C. "Try to take some deep breaths, and I'm sure you'll feel better." D. "Why do you feel that you need to leave?"

Correct Answer is A

Explanation

Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.

Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.

Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.

Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.

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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 reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

Correct Answer is C

Explanation

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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