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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is essential to prevent falls, which are a common and serious risk for the elderly. A clutter-free environment allows for safe and easy mobility.
B. Raising the bed, can actually increase the risk of falls if the bed is too high for safe exit.
C. Bright lighting can cause glare and visual discomfort for elderly individuals, especially those with age- related eye conditions such as cataracts or macular degeneration. However, adequate lighting is crucial for safety. The key is to provide sufficient lighting that is evenly distributed and free of glare or harsh shadows, which can help prevent falls.
D. While keeping linens away from the nursing uniform is good practice for infection control, it does not directly relate to the immediate physical safety of the client in the same way that a clear environment does.
Correct Answer is ["B","E"]
Explanation
B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.
E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.
A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.
C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.
D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.
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