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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Correct Answer is C
Explanation
The nurse should arrange for a video conference with an interpreter who speaks the client's language to provide discharge instructions. This ensures that the client receives accurate and complete information in a language they understand. The other
a. Assistive personnel may not be trained or qualified to provide medical interpretation.
b. Family members may not have the necessary medical knowledge to accurately translate medical information.
d. Simply indicating printed instructions in the client's language may not be sufficient to ensure the client understands the information.
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