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 C

Explanation

A. Serum glucose of 118 mg/dL: This value is slightly above the normal range but not critically elevated; it does not typically require immediate notification to the surgeon.
B. Blood urea nitrogen (BUN) of 16 mg/dL: This BUN level is within the normal range and does not suggest an immediate concern for surgical risk.
C. Serum sodium of 130 mEq/L: A serum sodium level of 130 mEq/L indicates hyponatremia, which can lead to serious complications including neurological symptoms and should be addressed prior to surgery.
D. Serum potassium of 3.9 mEq/L: This level is within the normal range and does not require immediate action related to surgery.

A. Serum potassium 3.2 mEq/L B. Pulse rate 65 bpm C. Hematocrit 36% D. Blood pressure 144/82 mmHg

Correct Answer is A

Explanation

A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.

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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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