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","C","E"]
Explanation
The correct answers are Choice B: "I must stop smoking.", Choice C: "I am limiting my intake of fast foods.", and Choice E: "I need to monitor my weight."
Choice A rationale:
Stopping alcohol consumption can have various health benefits, but moderate alcohol consumption is not a primary risk factor for coronary artery disease. Instead, excessive drinking is more concerning.
Choice B rationale:
Smoking is a significant risk factor for coronary artery disease. Quitting smoking greatly reduces the risk and improves overall cardiovascular health.
Choice C rationale:
Limiting fast food intake is an important dietary change, as fast foods are often high in unhealthy fats, salt, and calories, which can contribute to coronary artery disease.
Choice D rationale:
The statement "I should lower my HDL cholesterol level" is incorrect. HDL cholesterol is considered "good" cholesterol and helps to protect against heart disease. Therefore, lowering HDL cholesterol would not be beneficial.
Choice E rationale:
Monitoring and maintaining a healthy weight is crucial for reducing the risk of coronary artery disease. Excess weight, particularly around the abdomen, is a known risk factor.
Correct Answer is B
Explanation
Choice A rationale:
Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.
Choice B rationale:
The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.
Choice C rationale:
Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.
Choice D rationale:
Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.
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