A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)
"I think my ankles look less swollen today."
"I felt a little dizzy when I got out of bed this morning."
"I feel as if my heart is beating very fast.
"I am a little short of breath today."
The CNA told me that my blood pressure was 150 over 98 this morning."
Correct Answer : C,D,E
C. Rapid heart rate (tachycardia) can be a sign of fluid overload, as the heart compensates for increased volume by beating faster to maintain cardiac output.
D. Shortness of breath (dyspnea) can indicate fluid overload, especially if it is new or worsening and associated with pulmonary congestion due to fluid accumulation.
E Elevated blood pressure can be a sign of fluid overload, as increased circulating volume can lead to hypertension.
A. This statement suggests a decrease in peripheral edema, which is a positive sign and does not typically indicate fluid overload. It may actually indicate improvement.
B. Dizziness can be a symptom of hypovolemia (low fluid volume) rather than fluid overload. It is not typically a specific sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the most direct and appropriate question to assess for dysuria. Dysuria is characterized by pain, discomfort, or burning sensation during urination. Asking this question helps the nurse to directly assess if the client is experiencing these symptoms.
B. This question is more relevant for assessing urinary frequency rather than dysuria. It is important for assessing other urinary symptoms but does not specifically address the characteristic pain or discomfort associated with dysuria.
C. This question is pertinent for assessing urinary retention or incomplete emptying of the bladder, which are different concerns from dysuria. It evaluates the client's perception of bladder emptying rather than pain or discomfort during urination.
D. This question is more relevant for assessing urinary hesitancy or urgency, which are related to bladder function but are not specific to dysuria. It addresses issues with urine flow dynamics rather than pain or discomfort during urination.
Correct Answer is D
Explanation
D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.
A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.
B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.
C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.