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?

Fever

Crackles in the lungs

Bradycardia

Flattened neck veins

Answer and Explanation

The Correct Answer is B

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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Correct Answer is B

Explanation

The correct answer is that the nurse should expect to find reduced sweat production when performing a skin assessment on an older adult client. As we age, our skin gradually loses its ability to produce sweat and oil, which can result in dry skin¹.

Options a, c and d are not expected findings when performing a skin assessment on an older adult client. Increased skin elasticity, increased production of oils and thickened outer layer of skin are not typical age- related changes.

A. Encourage the client to take sips of water. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation. D. Encourage the client to breathe deeply and cough.

Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

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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 performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

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