What would the nurse be most concerned about?

Nursing Students NCLEX

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So... studying for NCLEX... which is FRIDAY! I've been reviewing Kaplan questions and came across one I thought I'd share.

"After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc. The nurse would be MOST concerned by which ot the following?

  1. A CVP reading or 12 and bradycardia.
  2. Tachycardia and hypotension.
  3. Dyspnea and oliguria.
  4. Rales and tachycardia."

Here's my logic. Automatically I think fluid overload. CVP (normal) and bradycardia wouldn't be expected, so scratch #1. Tachycardia in #2 fits but hypotension does not (scratch that). That leaves "dyspnea and oliguria" and "rales and tachycardia." Oliguria would not be a sign, necessary, of "fluid overload," but the question doesn't ask "what would you expect to find?" It asks "what would be the most concerning?" As I see it, rales and tachy would be expected with the patient, but if I realized the patient I just gave 850 ml of fluid to in an hour also had renal insufficiency or failure of some kind, I would be much more "CONCERNED." Well the correct answer, according to Kaplan, was #4. The rational on number #3 said "does not contain information relevant to fluid overload." I didn't interpret the question that way though.

Am I overanalyzing? How can I avoid making these same mistakes on NCLEX? Any thoughts?

Honestly...I thought right away about airway/breathing...since there was surgery performed. The MOST concerned cenario here is the rales and tachycardia. Also, 850 cc is a lot so yes, fluid overload.

Think about it this way...imagine 4 different patients, each one with what is stated in the options. What's the one that would make you more concerned?

I think you read into the question. Just use what the question gave you, you can't assume anything.

I hope this helps... :uhoh3:

I would of checked 4 too. The question didn't say anything about renal failure.

I picked 4 as well. Your process of elimination was right until you got to 'oliguria' You started to read into the question which is fatal for NCLEX. There was nothing in the question stem about renal failure.

I thought fulid overload immediatly and Iknow rales are never good, usually they are a sight of wet lungs or fluids and i figure fast HR as the heart will be working extra hard to pump.

First: DON'T READ INTO THE QUESTION!!!!!

When it says "Most Concerned" you look for something NOT EXPECTED. So if Tachycardia is a sign of fluid overload.... perhapes we should be looking for signs that are not. I would panic if a client was having symptoms that was completely un associated with the current condition....

i picked 4 as well...i chose the one that had the worse symptoms and was thinking fluid overload

so the key here is... only pick answers that rate directly to information in the question and don't look for other problems. and don't think in terms of real life scenarios.

Thanks for you input. wish me luck... 18 hours and counting... :uhoh3:

@ RnfromUK

My point exactly. If in real life my patient had developed a renal problem and i just flushed him with 1000 ml of fluid, i would be MOST CONCERNED! obviously I would EXPECT to see fluid overload, but a patient with a functioning kidney should be able compensate for the fluid imbalance. However if you add oliguria to the mix, then you have a real problem and would be MOST CONCERNED. In real life. But this is the not -- its NCLEX. I've got to remind myself -- Don't read into the question or think in terms of real life. If the answer choice has nothing to do with the information in the question, don't try to make it fit. :/

Also all parts of an answer has to be write:

I eliminated #2 because even though Tachy goes with fluid overload, hypotension doesn't usually

Hurst: Too much volume, too much pressure

Too little volume, too little pressure

There was too much volume so I ruled out hypotention- which means the #3 has a part right component and part wrong so discard that choice because they both have to be right

Good luck!

Specializes in Derm, Plas, OB-GYNE & Internal Medicine.
so the key here is... only pick answers that rate directly to information in the question and don't look for other problems. and don't think in terms of real life scenarios.

Thanks for you input. wish me luck... 18 hours and counting... :uhoh3:

YES. Also, I used my own simple technique on how to answer:

R-ead the question. Take note of keywords, lab values, disease, client situation

E-valuate each option ONE AT A TIME

*and the most important step*

D-oes it make sense? meaning is it based on nursing manuals/books not in real world practice

D-oes it really answer the question?

GOOD LUCK ON YOUR EXAMS. :)

@ Sara

client's renal status was not mentioned. why would you be concerned of oliguria over rales?

always remember.... IV fluid administration. VEIN TO BLOODSTREAM TO HEART TO LUNGS TO KIDNEY AND to D REST OF THE ORGANS.

so fluid overload means cardiac overload means pulmonary overload means renal overload.....................

After looking at this question, although #4 is certainly important, I feel I would go with #2. Hypotension and tachycardia are signs of shock, and mean that the patient is in deep trouble. Although rales and tachycardia are not a good sign, hypotension and tachycardia are worse, as they indicate that the patient's heart cannot handle the additional fluid. The patient with tachycardia and hypotension needs immediate treatment and may even need CPR and the crash cart. In contrast, rales and tachycardia are problematic, but may be just within the realm of what Lasix can handle, so long as the patient has a working kidney and is not hypotensive.

That being said, full disclosure that I am only a student at this moment, and this is just my thinking based on what I know so far. My idea may change with more experience.

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