A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Bradycardia

Flattened neck veins

Fever

Crackles in the lungs

Answer and Explanation

The Correct Answer is D

This is because crackles are a sign of fluid overload in the lungs, which can occur when a client receives too much IV fluid. Fluid overload can cause pulmonary edema, which is a life threatening condition that reduces oxygen exchange in the lungs. Some other signs and symptoms of fluid overload include rapid weight gain, swelling in the arms, legs and face, high blood pressure and shortness of breath.

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Correct Answer is C

Explanation

A total laryngectomy is a surgical procedure that removes the entire larynx (voice box) and separates the airway from the mouth, nose and esophagus. The client will have a permanent tracheostomy (an opening in the neck) and will not be able to speak normally. An artificial larynx is a device that produces sound by vibrating against the neck or cheek and allows the client to communicate orally. The nurse's priority intervention is to review the use of an artificial larynx with the client before surgery to facilitate postoperative communication and reduce anxiety.

A. Secure the tracheostomy ties to allow one finger to fit snugly underneath. B. Soak the outer cannula in warm, soapy tap water. C. Use a cotton tip applicator to clean inside the inner cannula D. Cleanse the skin around the stoma with normal saline.

Correct Answer is A

Explanation

A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath, so that they are not too tight or too loose.

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A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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