A nurse is collecting data from a client who is receiving IV fluids for dehydration. Which of the following findings should indicate to the nurse the client is experiencing fluid volume excess?

The client has tenting after pinching the skin on the hand.

The client's urinary output is 25 mL/hr for the past 4 hr.

The client experiences orthostatic hypotension when moving to a standing position.

The client has distended neck veins when moved to an upright position.

Answer and Explanation

The Correct Answer is D

A. The client has tenting after pinching the skin on the hand:
Skin tenting is a sign of dehydration, not fluid volume excess.

B. The client's urinary output is 25 mL/hr for the past 4 hr:
Low urine output (oliguria) indicates dehydration or kidney impairment, not fluid overload.

C. The client experiences orthostatic hypotension when moving to a standing position:
Orthostatic hypotension is more common in dehydration or blood loss.

D. The client has distended neck veins when moved to an upright position:
Jugular vein distention in an upright position is a classic sign of fluid volume excess due to increased venous pressure.

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Correct Answer is C

Explanation

A. Placing the client in a room with negative air pressure:
Negative pressure rooms are required for airborne precautions (e.g., tuberculosis), not droplet precautions.

B. Placing the client in a room with positive air pressure:
Positive pressure rooms are used for immunocompromised clients, not for droplet isolation.

C. Wearing a mask when assisting the client to rise to the restroom:
Droplet precautions require wearing a surgical mask within 3 feet of the client to prevent transmission via large respiratory droplets.

D. Wearing a gown when delivering the client's meal tray:
Gowns are worn when contact with body fluids or contaminated surfaces is anticipated, not simply for delivering food to a droplet-precaution patient.

A. Document in the nurses' notes that an incident report was completed. B. Record the facts about the incident in the medical record. C. Provide the family with a copy of the incident report. D. Place a copy of the incident report in the medical record.

Correct Answer is B

Explanation

A. Document in the nurses' notes that an incident report was completed:
This is incorrect. The incident report is an internal risk management tool and should not be mentioned in the medical record.

B. Record the facts about the incident in the medical record:
The nurse should document objective facts about the event, assessment, and interventions in the client’s medical record without referencing the incident report.

C. Provide the family with a copy of the incident report:
Incident reports are confidential and not shared with clients or families.

D. Place a copy of the incident report in the medical record:
This is incorrect; incident reports are kept separately from the medical record to avoid legal complications.

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A nurse is collecting data from a client who is receiving IV fluids for dehydration. Which of the following findings should indicate to the nurse the client is experiencing fluid volume excess?

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Naxlex Comprehensive Predictor Exams

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