The nurse determines that a patient has a fluid volume overload after assessing which of the following?
1. current weight 1 kg less than 2 days prior
2. hand vein distention for 10 seconds
3. lung sounds clear in both bases
4. low CVP reading
2
Rationale: Hand vein distention that does not clear within 5 seconds may indicate fluid volume overload. A weight loss of 1 kg represents a body water loss of 2.2 lbs which would not support fluid volume overload. Clear lung sounds means that no fluid is accumulating in the lungs and would not support fluid volume overload. A low central venous pressure reading would indicate a fluid volume deficit.
You might also like to view...
In trying to understand other cultures, what should the nurse know about how cultural values influence health beliefs?
1. Cultural values will not matter if the nurse is from the dominant culture. 2. Cultural values may shape perceptions of health, disease, prevention, and treatment. 3. Cultural values will not shape perceptions of health, disease, prevention, and treatment. 4. Cultural values and other differences will negatively influence outcomes.
At the beginning of rounds when entering the room, what should the nurse do first?
a. Check the intravenous (IV) infusion site for swelling or redness. b. Check the infusion pump settings for accuracy. c. Make eye contact with the patient, and introduce him or herself as the patient's nurse. d. Offer the patient something to drink.
The patient has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. The patient informs the nurse that she is feeling better and is stopping the medication because she has taken it for 4 days
What information should the nurse provide to this patient? A) Keep the remaining tablets for an infection at a later time. B) Discontinue the medications if the fever is gone. C) Dispose of the remainder of the medication in a biohazard receptacle. D) Antibiotics must be completed to eliminate the organism.
You are examining a patient with lymphedema. You would most likely discover which of the following findings?
a. fatigue c. weight loss b. swelling in the extremities d. night sweats