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 C

Explanation

Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.

Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.

Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.

Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.

A. Serve individual items that have sealed packaging. B. Serve warm foods that arrive from the kitchen with lids in place. C. Serve the same food that other clients in the dining room are eating. D. Serve the client's favorite foods in an attractive arrangement.

Correct Answer is A

Explanation

Choice A reason: Serving food in sealed packaging can help alleviate the client's fears of poisoning, as the intact seals provide visual assurance that the food has not been tampered with.

Choice B reason: While serving warm foods with lids may keep the food warm, it does not necessarily provide the same level of reassurance against the fear of poisoning as sealed packaging does.

Choice C reason: Serving the same food as others may not be effective if the client's delusions include beliefs that they are being specifically targeted.

Choice D reason: Although serving the client's favorite foods in an attractive arrangement may be appealing, it does not address the specific paranoid delusion of food being poisoned.

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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.)

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Naxlex Comprehensive Predictor Exams

Which of the following is a priority when caring for a highly anxious patient?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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