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. Isotonic solution B. Total Parenteral Nutrition (TPN) C. Hypertonic solution D. Hypotonic solution

Correct Answer is D

Explanation

A) Isotonic solution: Isotonic solutions, such as 0.9% sodium chloride, maintain the current sodium levels and fluid balance but do not correct hypernatremia. They are not suitable for lowering elevated sodium levels.

B) Total Parenteral Nutrition (TPN): TPN is used for providing comprehensive nutritional support and does not address electrolyte imbalances such as hypernatremia. It is not used to manage sodium levels directly.

C) Hypertonic solution: Hypertonic solutions, such as 3% sodium chloride, increase sodium levels and are used for treating hyponatremia or specific conditions requiring higher sodium concentrations. They would worsen hypernatremia.

D) Hypotonic solution: Hypotonic solutions, like 0.45% sodium chloride (half-normal saline) or Dextrose 5% in water (D5W), are appropriate for treating hypernatremia. They help dilute the sodium concentration in the blood and aid in correcting the elevated sodium levels

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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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