A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Blood in the tubing close to the insertion site

Chills, fever, and generalized discomfort

Pallor, sweating, and discomfort at the insertion site

Dyspnea, headache, and increased blood pressure

Answer and Explanation

The Correct Answer is D

A. Blood in the tubing close to the insertion site: This indicates a possible issue with the IV but not fluid overload specifically.
B. Chills, fever, and generalized discomfort: These symptoms may suggest an infection or reaction but are not specific to fluid overload.
C. Pallor, sweating, and discomfort at the insertion site: These could indicate a local reaction or issue with the IV site but not fluid overload.
D. Dyspnea, headache, and increased blood pressure: These symptoms are indicative of fluid overload, as the body reacts to excessive fluid with symptoms such as difficulty breathing (dyspnea), increased blood pressure, and headaches.

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Correct Answer is B

Explanation

A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.

A. Poorly controlled pain, moves all extremities, reports continued nausea B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side C. Afebrile, adventitious breath sounds, responds to painful stimuli D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex

Correct Answer is D

Explanation

A. Poorly controlled pain, moves all extremities, reports continued nausea: Poorly controlled pain and nausea are not ideal for discharge, as they indicate the patient might need further monitoring and management.
B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side: Low urinary output and low oxygen saturation indicate potential complications that require further assessment and treatment.
C. Afebrile, adventitious breath sounds, responds to painful stimuli: Responding to painful stimuli and adventitious breath sounds suggest the patient may still be experiencing complications and is not ready for discharge.
D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex: This response indicates stable oxygen saturation, stable vital signs, and an active gag reflex, suggesting the patient is ready for discharge from the PACU.

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A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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