NCLEX-PN® ExaminationPhysiological AdaptationEasy
A 68-year-old client with a history of heart failure is admitted with increased shortness of breath and peripheral edema. The nurse notes crackles in bilateral lung bases and a weight gain of 3 kg (6.6 lbs) over 2 days. Which of the following physician orders should the nurse question?
- AContinue IV infusion of 0.9% Normal Saline at 125 mL/hr.
- BMonitor daily weights and intake/output.
- CRestrict fluid intake to 1000 mL per 24 hours.
- DAdminister furosemide 40 mg IV push now.
Show answer & explanationAnswer & explanation
Correct answer: A. Continue IV infusion of 0.9% Normal Saline at 125 mL/hr.
The client's symptoms (shortness of breath, crackles, edema, weight gain) are indicative of fluid volume overload, a common complication of heart failure. Administering 0.9% Normal Saline at 125 mL/hr would exacerbate this condition by adding more fluid to the circulatory system, making this order inappropriate.
Why the other options are wrong
- B. Monitoring daily weights and intake/output are essential assessments for evaluating fluid balance and treatment effectiveness.
- C. Fluid restriction is a standard intervention for managing fluid volume overload in heart failure.
- D. Furosemide is a diuretic that helps remove excess fluid, which is appropriate for fluid volume overload.
Fluid Volume Overload (Hypervolemia)
An excess of fluid in the extracellular compartment, often caused by compromised regulatory mechanisms (e.g., heart failure, kidney failure) or excessive intake.
- Causes include heart failure, kidney failure, excessive IV fluid administration.
- Symptoms include edema, crackles, shortness of breath, weight gain, elevated blood pressure.
- Treatment focuses on fluid restriction, diuretics, and addressing the underlying cause.
Memory trick: Too Much Water, Heart Can't Hold It!