A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?

Edema

Oliguria

Hypotension

Hyperthemia

Answer and Explanation

The Correct Answer is A

A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.

B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.

C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.

D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature

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Correct Answer is D

Explanation

A) D5W: Dextrose 5% in water (D5W) is not used with blood transfusions because it can cause hemolysis of the red blood cells due to its hypotonic nature. It can also potentially cause clumping and clotting.

B) 0.3% NS: This is a hypotonic saline solution, which can lead to hemolysis of red blood cells when used as a diluent for blood products. It is not appropriate for use in blood transfusions.

C) Lactated Ringers: Although lactated Ringer's solution is often used for fluid resuscitation, it contains calcium, which can cause clotting in the blood product. Therefore, it is not suitable for use with blood transfusions.

D) 0.9% NS: Normal saline (0.9% sodium chloride) is isotonic and the only solution recommended for use with blood transfusions. It does not cause hemolysis of red blood cells, does not alter the composition of the blood product, and helps to maintain the patency of the IV line. It is the standard diluent used in blood transfusions to ensure the safe administration of blood products.

A. The client is reporting constipation. B. The client reports being thirsty C. The client is vomiting the enteral formula. D. The client is experiencing abdominal cramping.

Correct Answer is C

Explanation

A) The client is reporting constipation:

Constipation is a common issue with enteral feeding, often due to decreased fluid intake or lack of fiber. While it is important to manage constipation to improve comfort and bowel function, it is not as urgent as dealing with vomiting.

B) The client reports being thirsty:

Thirst can be a sign of dehydration or inadequate fluid intake. Although it should be addressed to ensure proper hydration, it is less critical compared to vomiting, which poses immediate risks.

C) The client is vomiting the enteral formula:

Vomiting is a priority concern because it can lead to aspiration, dehydration, electrolyte imbalances, and further complications. Addressing the cause of vomiting and managing it promptly is crucial for the client’s safety.

D) The client is experiencing abdominal cramping:

Abdominal cramping can be related to the feeding rate, type of formula, or intolerance. While it requires attention, it is less urgent than addressing vomiting, which could have more immediate and serious consequences.

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A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?

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Explanation

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