A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

Jugular vein distention

Crackles

Dyspnea

Hypotension

Flat veins

Answer and Explanation

Correct Answer : A,B,C

A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.

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Correct Answer is A

Explanation

A. Encouraging the client to change positions slowly, such as moving from lying to sitting and then to standing, helps to minimize the risk of orthostatic hypotension. This gradual change allows the body to adjust to positional changes without causing a sudden drop in blood pressure.
B. Encouraging vigorous exercise is not recommended for a client with hypovolemia as it could exacerbate the condition, potentially causing dizziness, fainting, or further lowering blood pressure.
C. Encouraging the client to stand for extended periods is not appropriate for a client at risk for orthostatic hypotension, as standing for prolonged periods can cause blood to pool in the lower extremities, increasing the risk of fainting or dizziness.
D. Encouraging the client to limit fluid intake is inappropriate for a client with hypovolemia. Adequate fluid intake is crucial to help restore blood volume and prevent hypotension.

A. Chocolate and peppermint candies. B. Oatmeal with banana slices. C. Spaghetti with tomato sauce. D. Cheeseburger with grilled onions.

Correct Answer is B

Explanation

A. Chocolate and peppermint can relax the lower esophageal sphincter, worsening GERD symptoms. These should be avoided.
B. Oatmeal with banana slices is a good choice because it is low in fat and acid, which helps prevent GERD symptoms. Bananas are also a non-acidic fruit that is generally well-tolerated.
C. Spaghetti with tomato sauce contains acidic ingredients that can irritate the esophagus and worsen GERD symptoms.
D. A cheeseburger with grilled onions is high in fat, which can delay gastric emptying and increase reflux. Onions are also a known trigger for GERD symptoms.

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A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

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