The nurse is providing care for a client with a fluid imbalance. The nurse explains that in the body, areas with high concentration of solutes naturally and passively shift to areas of lower concentration. The nurse is describing which process?

Choice A reason: This is not a correct finding for hypervolemia. Hypotension is a low blood pressure, which can be caused by hypovolemia (low blood volume) or other factors. Hypervolemia is an excess of fluid in the body, which can increase the blood pressure.

Choice B reason: This is not a correct finding for hypervolemia. Bradycardia is a slow heart rate, which can be caused by heart block, medication, or other factors. Hypervolemia can cause tachycardia (fast heart rate) as the heart tries to pump the excess fluid.

Choice C reason: This is a correct finding for hypervolemia. Peripheral edema is a swelling of the extremities due to fluid accumulation in the tissues. Hypervolemia can cause peripheral edema as the fluid leaks from the blood vessels into the interstitial spaces.

Choice D reason: This is not a correct finding for hypervolemia. Weight loss is a decrease in body weight, which can be caused by dehydration, malnutrition, or other factors. Hypervolemia can cause weight gain as the body retains more fluid.

Choice A reason: Securing the drain to the client's bed sheet is not the best action for the nurse to take. This could cause the drain to be pulled or dislodged if the client moves or changes position. The nurse should secure the drain to the client's gown or abdominal binder, using a safety pin or a clip.

Choice B reason: Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze, is not the correct action for the nurse to take. The nurse should not remove the drain without a physician's order, as this could cause complications such as infection, bleeding, or bile leakage. The nurse should monitor the amount and color of the drainage, and report any changes to the physician.

Choice C reason: Expelling the air from the JP bulb after emptying to re-establish suction is the correct action for the nurse to take. The JP drain works by creating a negative pressure that draws fluid from the surgical site. The nurse should empty the bulb when it is half full, and squeeze it until it collapses before closing the plug. This ensures that the suction is maintained and prevents the fluid from flowing back into the drain.

Choice D reason: Measuring the drainage every hour for the first 8 hr postoperative is not the correct action for the nurse to take. This is too frequent and unnecessary, as the drainage is expected to decrease over time. The nurse should measure the drainage every 8 to 12 hr, or as ordered by the physician, and record the volume and color. The nurse should also report any signs of infection, such as fever, pain, or foul odor.