A nurse is caring for a client who has fluid overload due to heart failure. Which of the following clinical manifestations should the nurse expect to find in the client?

The correct answer is: c. Crackles in the lungs

Choice A: Dry mucous membranes

Reason: Dry mucous membranes are typically associated with dehydration, not fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms such as edema and pulmonary congestion, rather than dryness of mucous membranes.

Choice B: Decreased urine output

Reason: Decreased urine output can occur in conditions like dehydration or renal failure. In fluid overload due to heart failure, the kidneys may initially try to excrete excess fluid, leading to increased urine output. However, as heart failure progresses, renal perfusion may decrease, potentially leading to reduced urine output. This is not a primary or consistent symptom of fluid overload.

Choice C: Crackles in the lungs

Reason: Crackles in the lungs are a hallmark sign of fluid overload, particularly in the context of heart failure. This occurs due to pulmonary edema, where excess fluid accumulates in the alveoli, causing the characteristic crackling sound during auscultation. This is a direct result of the heart’s inability to effectively pump blood, leading to fluid backing up into the lungs.

Choice D: Hypotension

Reason: Hypotension, or low blood pressure, is not typically associated with fluid overload. In fact, fluid overload can often lead to hypertension (high blood pressure) due to the increased volume of fluid in the circulatory system. Hypotension might occur in severe heart failure if the heart’s pumping ability is significantly compromised, but it is not a primary manifestation of fluid overload.

Choice A reason:

Administering calcium gluconate IV as prescribed is an intervention that the nurse should include in the plan for a client who has hypocalcemia. Calcium gluconate is a calcium supplement that can increase the serum calcium levels and treat hypocalcemia. It should be given slowly and carefully to avoid extravasation and tissue necrosis.

Choice B reason:

Monitoring for Chvostek's sign and Trousseau's sign is an intervention that the nurse should include in the plan for a client who has hypocalcemia. Chvostek's sign is a facial twitching that occurs when the facial nerve is tapped near the ear. Trousseau's sign is a carpal spasm that occurs when a blood pressure cuff is inflated above the systolic pressure for several minutes. Both signs indicate increased neuromuscular excitability due to low calcium levels.

Choice C reason:

Encouraging intake of foods high in calcium and vitamin D is an intervention that the nurse should include in the plan for a client who has hypocalcemia. Calcium and vitamin D are essential nutrients for bone health and calcium metabolism. Foods high in calcium include dairy products, green leafy vegetables, tofu, sardines, and fortified cereals. Foods high in vitamin D include fatty fish, egg yolks, cheese, and fortified milk.