A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
Intake 2,400 mL, output 2.500 mL
Intake 1,200 mL, output 700 mL
Intake 800 mL output 2,100 mL
Intake 2.500 mL output 500 mL
The Correct Answer is A
A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.
B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.
C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.
D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.
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Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is C
Explanation
C. This method is recommended because it is less painful, as the sides of the fingertips have fewer nerve endings compared to the pads or 'balls' of the fingers.
A. Avoiding the use of the thumbs is not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
B. Avoiding the use of the dominant hand's fingers are not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
D. Using the ball of the finger is not recommended for blood glucose monitoring because it can be more painful and may lead to less blood flow, resulting in difficulty obtaining an adequate blood sample.
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