A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Crackles in lung bases.

Periorbital edema.

Swelling at the IV site.

Bounding radial pulse.

Flat neck veins when supine.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.

Choice B rationale:

Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.

Choice D rationale:

Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.

Choice C rationale:

Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.

Choice E rationale:

Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.

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Correct Answer is A

Explanation

Choice A rationale:

Bananas are a good source of potassium, and the client's serum potassium level is low (3.1 mEq/L). Including potassium-rich foods like bananas in the diet can help raise the potassium level and prevent hypokalemia, which is a potential side effect of furosemide (a diuretic).

Choice B rationale:

Cheddar cheese is not a suitable choice for a client with low potassium levels. It is not a significant source of potassium and should not be the primary recommendation for addressing hypokalemia.

Choice C rationale:

Cabbage is not a good choice for increasing potassium intake. While it has some potassium, other fruits and vegetables like bananas are much richer sources of this essential electrolyte.

Choice D rationale:

White rice is not a high-potassium food and should not be the first choice for a client with low potassium levels.

A. Hypertension. B. Diaphoresis. C. Muscle tetany. D. Increased thirst.

Correct Answer is C

Explanation

Choice A rationale:

Hypertension is not typically associated with low calcium levels. Hypertension is more commonly linked to issues with blood pressure regulation and not calcium levels.

Choice B rationale:

Diaphoresis (excessive sweating) is not a direct symptom of low calcium levels. Low calcium can lead to muscle cramps and tetany, but not sweating.

Choice C rationale:

Muscle tetany is a common manifestation of low calcium levels (hypocalcemia). It results from increased neuromuscular excitability, causing muscle spasms and contractions. A calcium level of 7 mg/dL is below the normal range, and this client is at risk for muscle tetany.

Choice D rationale:

Increased thirst is not a typical symptom of low calcium levels. Symptoms of hypocalcemia are primarily related to neuromuscular and cardiovascular changes, such as muscle tetany and cardiac arrhythmias.

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A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).