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 A

Explanation

Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.

Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.

Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.

Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.

A. Develop the patient's plan of care. B. Provide informed consent to the patient. C. Provide emotional support to patients. D. Assist with data collection. E. Include families in preoperative care. F. Reinforce patient teaching.

Correct Answer is ["C","D","E","F"]

Explanation

Choice A reason: LPNs are involved in developing the patient's plan of care by gathering data and collaborating with the RN to ensure the plan is tailored to the patient's needs.

Choice B reason: Providing informed consent is typically the responsibility of the physician or advanced practice nurses, not the LPN.

Choice C reason: LPNs provide emotional support to patients, helping to alleviate anxiety and offering comfort before the surgery.

Choice D reason: LPNs assist with data collection, such as gathering vital signs and medical history, which is crucial for the preoperative assessment.

Choice E reason: Including families in preoperative care is part of the holistic approach to nursing, where LPNs can provide information and support to the patient's family.

Choice F reason: LPNs reinforce patient teaching by reviewing instructions and care plans with the patient and their family to ensure understanding and compliance.

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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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