A client who is postoperative is receiving IV fluids and a unit of whole blood.
The nurse should observe the client for which of the following as an early sign of circulatory overload?
Bradycardia.
Dyspnea.
Flushing.
Vomiting.
The Correct Answer is B
Choice A rationale:
Bradycardia, or a slow heart rate, is not typically an early sign of circulatory overload.
Choice B rationale:
Dyspnea, or difficulty breathing, is an early sign of circulatory overload. This occurs because the heart is unable to pump the excess blood effectively, leading to fluid buildup in the lungs.
Choice C rationale:
Flushing, or reddening of the skin, is not typically an early sign of circulatory overload.
Choice D rationale:
Vomiting is not typically an early sign of circulatory overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Discarding any partial doses found in the cabinet in the sharps container is not the correct procedure. Partial doses should be wasted in the presence of another nurse.
Choice B rationale:
Verifying that the amounts of each medication counted match the amounts on the inventory record is the correct procedure. This ensures accurate accounting of controlled substances.
Choice C rationale:
Setting aside any controlled substances the nurse plans to give during her shift is not the correct procedure. Medications should be removed from the secure cabinet as needed.
Choice D rationale:
Co-signing any notations of wasting controlled substances on the previous shift is not the correct procedure. Wasting should be witnessed and co-signed at the time it occurs.
Correct Answer is B
Explanation
Choice A rationale:
Placing the client in a modified Trendelenburg position is not the first action to take when managing a heavily bleeding wound.
Choice B rationale:
Applying direct pressure to the wound is the first action to take to control bleeding.
Choice C rationale:
Elevating the extremity can help control bleeding, but it is not the first action to take.
Choice D rationale:
Applying a tourniquet is a last resort when other methods of controlling bleeding have failed.
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