A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

A) The client reports dizziness when ambulating to the bathroom:
Dizziness upon ambulation is a key indicator that the client may be experiencing orthostatic hypotension, a potential side effect of antihypertensive medications. If the client is already experiencing dizziness, this could be exacerbated by administering the medication, which may cause a further drop in blood pressure. It is crucial for the nurse to further assess the client’s blood pressure (particularly orthostatic blood pressure readings) and overall clinical status before administering the medication to prevent potential falls, injury, or worsening hypotension.

B) The client reports having trouble sleeping the previous night:
While difficulty sleeping could be a concern, it is not directly related to the administration of an antihypertensive medication unless the client reports other symptoms, such as palpitations, chest pain, or anxiety, which may indicate an underlying issue. It is not a priority to delay or further assess medication administration based solely on sleep disturbances unless other significant factors are present.

C) The client ate 60% of their breakfast:
Eating 60% of the meal is not typically a reason to withhold or delay antihypertensive medication unless the client is showing signs of severe nausea, vomiting, or gastrointestinal distress. Many antihypertensive medications can be taken with food to reduce gastric irritation, and this percentage of food intake does not pose an immediate concern.

D) The client has a urine output of 400 mL for the past 8 hours:
Urine output of 400 mL over 8 hours is within the normal range (approximately 50–60 mL/hr), suggesting adequate renal function and fluid balance. While a decrease in urine output can be concerning, there is no immediate indication that this level of output would interfere with the administration of an antihypertensive medication.

A) Prepares the sterile field 2 hours before it is needed:
A sterile field should be prepared as close to the time it will be used as possible, typically within 15 to 30 minutes before the procedure, to ensure its sterility is maintained. Preparing a sterile field 2 hours in advance increases the risk of contamination, as airborne particles and bacteria can settle on the field during that time.

B) Uses a surface that is at waist height:
A waist-height surface is the most appropriate for setting up a sterile field. This is because it allows the nurse to maintain a proper stance and reduces the likelihood of contamination by minimizing the risk of the nurse accidentally reaching over or leaning into the sterile field. The correct height ensures that sterile items are not contaminated by being positioned too high or too low, both of which can increase the risk of contamination.

C) Places the sterile field against a wall in the client's room:
Placing the sterile field against a wall is not advisable, as it may increase the likelihood of contamination. A wall is not a sterile surface, and anything in close proximity to the wall (e.g., furniture, equipment) could inadvertently contaminate the sterile field. A sterile field should be placed on a clean, flat surface that is free from any potential contaminants, away from traffic or other surfaces that could compromise sterility.

D) Opens the first flap of the sterile package towards the nurse's body:
When opening a sterile package, the first flap should always be opened away from the body, not towards it. This action ensures that the nurse does not risk contaminating the sterile field by inadvertently touching it with their body or clothing. The nurse should open each flap of the sterile package away from themselves, then discard it, continuing to open the remaining flaps in a way that maintains the sterility of the items within.