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 A

Explanation

A condom catheter is a urine collection device that fits like a condom over the penis and has a tube that goes to a collection bag strapped to the leg. To apply a condom catheter, the nurse should clean and dry the penis thoroughly, unroll the sheath over the penis, leaving 2.5 to 5 cm (1 to 2 in) of space between the end of the catheter and the tip ofthe penis, and gently squeeze the catheter around the penis shaft for 10 to 15 seconds to ensure adhesion.

A. Suction the client's airway every hour. B. Offer the client sips of a citrus flavored soda. C. Position the client supine in bed. D. Encourage the client to make choices regarding hygiene.

Correct Answer is D

Explanation

The nurse should encourage the client to make choices regarding hygiene, as this respects the client's autonomy and dignity. Suctioning the client's airway every hour is incorrect because it may cause discomfort and distress to the dying client. Offering the client sips of a citrus flavored soda is incorrect because it may irritate the client's mouth and throat, which are often dry and sensitive at the end of life. Positioning the client supine in bed is incorrect because it may increase the risk of aspiration and airway obstruction, as well as pressure ulcers.

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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 preparing to apply a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?

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