A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Bounding pulse.

Elevated temperature.

Warmth at IV site.

Profuse sweating.

Crackles in lungs.

Answer and Explanation

Correct Answer : A,E

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

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Correct Answer is D

Explanation

Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.

Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.

Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.

Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.

A. Get plenty of outdoor exercise all year. B. Keep affected body areas covered at all times. C. Take vasopressors to prevent exacerbation of symptoms. D. Avoid stimulation that causes vasoconstriction.

Correct Answer is D

Explanation

Choice A reason: Getting plenty of outdoor exercise all year is beneficial for overall health but does not specifically prevent Raynaud's attacks, especially in cold weather.

Choice B reason: Keeping affected body areas covered, especially in cold weather, helps prevent Raynaud's attacks by maintaining warmth.

Choice C reason: Taking vasopressors is not a measure to prevent Raynaud's attacks; vasopressors could potentially worsen the condition by causing further vasoconstriction.

Choice D reason: Avoiding stimulation that causes vasoconstriction, such as stress and cold temperatures, is key to preventing Raynaud's attacks.

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A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Nursing Test Bank

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