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."

Answer and Explanation

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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Correct Answer is ["1705"]

Explanation

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

A. “I can understand your concern about learning to inject yourself." B. "Good morning. How did you sleep last night?" C. "Can you describe what the pain in your abdomen feels like?" D. "Do you mean you would like to talk to the nurse practitioner?

Correct Answer is A

Explanation

A. This response acknowledges the patient's concern directly. It demonstrates empathy by indicating that the nurse understands the client's feelings of apprehension or anxiety about self-injection. By expressing understanding, the nurse shows empathy towards the client's emotional state.

B. This question shows concern for the patient's well-being and invites them to share their experiences. While it demonstrates a caring attitude, it focuses more on physical comfort rather than directly addressing the client's emotional concerns. While this question shows a caring attitude, it doesn't specifically convey empathy regarding the client's emotional state or concerns.

C. This question seeks to gather information about the client's symptoms. It shows clinical interest and concern for the client's physical condition, but it doesn't directly convey empathy towards their emotional state or concerns. This question is important for assessing the client's condition but does not demonstrate empathy towards their emotional experience or concerns.

D. This response seeks clarification on the client's request or statement. It shows willingness to understand the client's needs or preferences. While it shows attentiveness and willingness to assist, it doesn't directly convey empathy towards the client's emotional concerns or validate their feelings.

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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)

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["1705"]

Explanation

Which response by the nurse best conveys empathy to the client?

Correct Answer is A

Explanation

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