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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.
a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.
d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can affect blood glucose levels.
c. PN and fat emulsions can be administered together in a single infusion.
Correct Answer is D
Explanation
When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.
Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.
Option b is incorrect because reading back the prescription to the provider is important but not the first action.
Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.
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